Syndemic lives of women who smoke and experience homelessness: secondary analysis of US qualitative data.

Tobacco use remains the leading cause of preventable deaths worldwide. Despite efforts by many countries to reduce the impact of tobacco products and lower smoking rates, smoking prevalence is higher among people experiencing homelessness. The reasons are complex and go beyond individual choices, including limited awareness about quitting, restricted access to services, and previous negative experiences. This study is a secondary data analysis of qualitative interviews with women experiencing homelessness. The original data were collected in 2021 as part of a study aimed at understanding tobacco behaviours, attitudes towards quitting, and factors influencing engagement for a subsequent randomized controlled trial. This secondary qualitative analysis, conducted in 2025, examines how policy and environmental contexts influence smoking behaviours among women experiencing homelessness using a social ecological model (SEM) framework. Data were categorized and mapped using the five specified categories within the SEM: policy and environment, community contexts, organizations and systems, interpersonal connections, and individual power and resource distribution. The participants show remarkable resilience in overcoming early-life and adolescent environmental and contextual hardships. Gaps in health services emphasize the need for aligned policy and service improvements. Using the SEM framework, which emphasizes the policy and environmental contexts, offers a deeper understanding of the context of women's lives. The evidence from this study supports the implementation of gender- and age-appropriate holistic approaches to healthcare and tobacco interventions tailored to this community.