Tobacco harm reduction for people experiencing homelessness: a qualitative study of lived experiences and service provider perspectives

Introduction Smoking rates are high among people experiencing homelessness. Targeted interventions need to address the specific challenges faced by this group. This qualitative study explores the experiences, and needs of service users and staff to inform the development of a tailored tobacco harm reduction (THR) toolkit for homeless services. Methods Focus groups and interviews with 24 service users and 20 staff from six homeless organizations in England, explored i) past experiences of THR; ii) how person-centred interventions and policies should feel to those receiving and delivering them; and iii) the types of THR support participants would find acceptable. Data were analyzed using thematic analysis, Iterative Categorization, and mapped onto COM-B model domains. Results Service users described limited capability to engage with THR, driven by poor literacy, limited eyesight and difficulty retaining information. Opportunities to address smoking were scarce; tobacco use was rarely discussed within services, reflecting norms and missed conversations. Motivation was present but constrained by external limitations: staff described feeling disempowered despite a clear desire to help, and service users often lacked support at key moments of readiness. Participants emphasized relational support, accessible and integrated provision, and small, achievable wins. Across both groups, optimism for harm reduction was frequently undermined by system gaps, including inconsistent access to tools and fragmented service pathways. Conclusion Effective THR in homelessness services must be relational, immediate, and embedded within everyday practice. Investment in staff capability, accessible resources, and non-judgemental approaches is needed to translate motivation into action and reduce smoking-related harm.