The foundation for the final report was laid earlier, when the first phase of the Pathways study was released in April 2026. That phase established, through hundreds of surveys, that 98 percent of unhoused participants wanted permanent housing, a figure that directly counters persistent public narratives suggesting that many people experiencing homelessness prefer to remain unsheltered. The second phase deepened that quantitative picture by pairing it with qualitative evidence. Researchers interviewed participants about the full arc of their experiences, from the circumstances that preceded housing loss to the slow, often contradictory process of engaging with homeless services. By combining statistical breadth with narrative depth, the study aimed to capture not just how many people are affected but how the pathway into and out of homelessness actually unfolds over time.

A distinctive methodological feature of the research was its co-design with the Transformational Research for Equity and Experience in Shelter committee, a group composed entirely of people with lived experience of homelessness. Rather than treating formerly and currently unhoused individuals as passive subjects, the research team positioned them as analytic partners capable of interpreting patterns in the data. One study participant captured the rationale plainly, noting that people with lived experience are often invited to share stories, but that their capacity to analyze those experiences matters just as much, because they understand the patterns rather than merely witnessing them. This participatory approach gave the report an insider’s view of how housing service systems are experienced from below, including the emotional and cognitive labor that participants expend simply trying to remain eligible for help.

Lead investigator Kathleen Conte, an assistant professor in the OHSU-PSU School of Public Health, summarized the core insight of the findings by explaining that navigating homelessness involves far more than locating a service and accepting it. People, she said, are simultaneously trying to stay safe, meet basic needs, decipher a complicated service system, prove they qualify for assistance, maintain important relationships, advocate for themselves and push forward through long waits and repeated setbacks. The report frames this as a continuous balancing act in which the demands of survival compete directly with the demands of bureaucratic engagement. Missing a call, losing a document or changing shelter locations can unravel weeks of progress, meaning that the population most burdened by the system is also the one asked to perform the most sustained administrative effort within it.

The journey mapping revealed that for many participants, outright homelessness was preceded by a period of hidden homelessness, including couch surfing, living in vehicles and temporary hotel stays. These precursors are largely invisible in official counts, which means the visible crisis often represents a late stage of a much longer decline. Bereavement emerged as a strikingly common trigger: more than 30 percent of interview participants reported that the death of a loved one directly or indirectly contributed to their housing loss. The finding underscores how fragile housing stability can be when household finances and social support depend on a single person’s income or presence, and it suggests that grief and loss deserve greater attention in prevention-oriented policy, which typically focuses on eviction, rent burdens and employment disruption.

Once unhoused, participants described becoming trapped in what the report calls “the churn,” a state in which continuous effort to secure housing is repeatedly frustrated by systemic bottlenecks. These include missing identification documents that are difficult to replace without a fixed address, high turnover among case managers that forces people to retell their histories again and again, and phone calls that simply go unreturned. One participant delivered a pointed assessment of the current service framework, describing it as a system that rewards maintenance rather than transformation. The phrase captures a structural critique: programs are often organized around keeping people engaged and documented rather than around moving them decisively into permanent housing, which can leave individuals indefinitely cycling through shelter beds, waitlists and intake appointments.

Administrative requirements and rigid program thresholds compounded the problem, creating what the researchers describe as a painful mismatch between a person’s immediate needs and the assistance actually available. Participants recounted being denied services because their situations did not fit precise priority definitions, leaving them to navigate fragmented systems without clear guidance about where to turn next. Lori Kelley, planning and evaluation manager for the Multnomah County Homeless Service Department, which supported the study, emphasized that effective policy must be grounded in reality and that the county’s goal was to center the real-world experiences of people using services throughout the entire research process. She described the research as giving policymakers and the public an honest look at what works, what does not and what truly prevents people from reaching their housing goals.

Importantly, the report does not conclude that escape from homelessness is impossible. Participants also described moments when the system worked, when the right support, relationships and opportunities converged at precisely the right time to move them toward housing. Yet the study found that these successes were more often experienced as lucky breaks than as reliable pathways, a distinction with significant policy implications. When exits from homelessness depend on fortunate timing rather than predictable system design, outcomes become inequitable and difficult to scale. The TREES committee pressed this point in its own contribution to the report, stressing that while numbers, charts and data are incredibly important, remembering the humans living without housing, and what those numbers represent, should be the priority guiding interpretation and action.

Based on the combined evidence, the report sets out six core priorities for action, developed in collaboration with the TREES committee. These include expanding diverse affordable housing models tailored to different ages, family structures, disabilities and safety needs; prioritizing prevention and housing stability through flexible early financial support and livable-wage employment before housing is lost; coordinating and standardizing services with centralized information points to reduce administrative runaround; eliminating practices such as involuntary displacements that strip people of belongings, legal documents and case manager relationships; strengthening community support systems through peer networks and culturally specific organizations; and integrating lived experience directly into funding decisions, program design, policy and research. Conte cautioned that no single organization can build the path alone, noting that people in crisis are asked to navigate housing, health care and other systems that do not always connect. If better pathways out of homelessness are the goal, she argued, those systems must work together rather than expecting people to find their own way without a map.

Subject of Research: A lived-experience study of the pathways people take through homelessness and homeless services in Multnomah County, Oregon.

Article Title: New PSU study maps complex journeys through homelessness in final pathways report

Article References: New PSU study maps complex journeys through homelessness in final pathways report. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: homelessness, Portland State University, Multnomah County, housing policy, lived experience, social services, public health, housing instability, poverty, homeless services, prevention, participatory research

The rationale behind EXIT begins with a candid assessment of why conventional cessation programs fail this population. The researchers identify structural inequities as central barriers: the lack of stable housing, limited access to treatment services, and the fragmentation of care that forces people to navigate multiple disconnected systems. Layered on top of these structural obstacles are high rates of serious mental illness and substance use disorders among homeless smokers, which compound the physiological grip of nicotine dependence. Existing cessation treatments, the authors note, are often brief in duration, rarely integrated into community service settings, and short on the kind of ongoing behavioral support that sustained quitting demands. A single counseling session and a starter pack of patches, in other words, is poorly matched to the realities of life without a home.

EXIT was engineered around two design principles that distinguish it from prior efforts. The first is duration: rather than offering weeks of support, the intervention extends pharmacotherapy and coaching across a full six months, reflecting evidence that longer treatment courses improve cessation odds. The second is accessibility: the intervention routes treatment through community pharmacies and delivers behavioral support by telephone, so participants do not need to travel to clinics, keep rigid appointments, or negotiate unfamiliar healthcare bureaucracies. Community pharmacies have long been recognized as a promising venue for expanding access to evidence-based tobacco treatment, because pharmacists are numerous, trusted, geographically distributed, and empowered in many states to prescribe or recommend nicotine replacement products. Until now, however, pharmacy-based approaches have mostly been tested in short-duration interventions, leaving open the question of whether they can sustain quitting over the long term.

The trial itself is a two-arm, parallel-group randomized controlled trial conducted in transitional shelters in Los Angeles and San Francisco, two cities where homelessness has reached crisis scale. The investigators plan to enroll 150 adults experiencing homelessness who smoke at least five cigarettes per day, whose tobacco exposure is confirmed objectively by an expired carbon monoxide reading of at least 8 parts per million, and who report an intention to quit within six months. That carbon monoxide threshold is an important methodological safeguard, ensuring that self-reported smoking status is corroborated by a biochemical marker before randomization. Participants will then be allocated, in equal numbers, either to the full EXIT intervention or to a pharmacist-only comparator condition, allowing the trial to isolate the added value of extended pharmacotherapy and wellness coaching.

The comparator arm is deliberately pragmatic. Dubbed the pharm-only condition, it consists of a single pharmacist-delivered telephone session structured around the 5As framework, the established clinical sequence of asking about tobacco use, advising cessation, assessing readiness, assisting with a quit plan, and arranging follow-up, plus three months of nicotine replacement therapy. This condition represents a reasonable standard of care that a person might receive through a well-functioning pharmacy-based service, making it a meaningful benchmark against which to measure EXIT’s incremental benefits. Any advantage observed for the full intervention can therefore be attributed with some confidence to the additional months of medication and the intensive coaching component, rather than to mere contact with the healthcare system.

EXIT builds on that foundation in two decisive ways. Participants in the intervention arm receive the same initial 5As session, but their nicotine replacement therapy extends to a full six months, doubling the comparator’s treatment duration. More distinctive still is the behavioral component: 14 wellness-focused telephone coaching sessions delivered over six months by trained health coaches. The framing of these sessions as wellness-focused rather than narrowly cessation-focused is a deliberate design choice. Coaching conversations encompass broader health behaviors, including diet and physical activity, alongside smoking cessation goals. The investigators anticipate that this holistic approach may improve engagement and retention among participants for whom smoking is only one of many competing health and survival concerns, and for whom a single-issue intervention may feel disconnected from their priorities.

The trial’s primary outcome is adherence itself, an unusually honest choice for a feasibility-stage study. Adherence will be measured by the number of coaching sessions attended and by participants’ adherence to the nicotine replacement regimen, since an intervention only works if people actually use it. Secondary outcomes include biochemically verified seven-day point prevalence abstinence at three and six months, again confirmed by carbon monoxide readings of 5 parts per million or below. Assessment visits occur at baseline and at one, three, and six months, capturing a rich panel of measures: tobacco use and nicotine dependence, health behaviors such as diet and physical activity, mental health, substance use, and adherence to nicotine replacement therapy. This longitudinal design allows the team to track not only whether people quit, but how the intervention reshapes the broader health landscape that sustains addiction.

Methodologically, the protocol reflects the iterative logic of modern behavioral intervention science. Rather than leaping directly to a large, fully powered effectiveness trial, the EXIT team is first testing feasibility, acceptability, and preliminary efficacy in the very settings where a scalable program would ultimately operate. This staged approach guards against the familiar failure mode of cessation interventions that perform well in controlled academic clinics but collapse when transplanted into community environments with high participant mobility, competing survival needs, and limited staffing. By embedding the trial within transitional shelters and partnering with pharmacy infrastructure from the outset, the investigators are stress-testing the delivery model under real-world conditions. The findings are explicitly intended to inform a future fully powered trial that could establish a scalable model for delivering tobacco cessation treatment to people experiencing homelessness nationwide.

The scientific significance of the trial extends beyond its immediate population. Smoking among homeless adults is a major driver of the stark mortality gap between housed and unhoused populations, contributing to cardiovascular disease, respiratory illness, and cancer at rates that dwarf the risks posed by many problems that receive far more public attention. Yet tobacco is frequently deprioritized in homeless services, treated as a concern to be addressed only after housing, addiction, and mental health needs are met. EXIT challenges that triage logic by demonstrating that evidence-based tobacco treatment can be woven directly into homeless services and pharmacy systems rather than deferred. The trial is funded by the California Tobacco-Related Disease Research Program, with additional support to the first author from the National Institute on Drug Abuse, and it is registered at ClinicalTrials.gov under identifier NCT07148232.

If EXIT proves feasible, acceptable, and even preliminarily effective, the implications could ripple across public health practice. A model that pairs six months of nicotine replacement with sustained telephone coaching, initiated through a pharmacist visit and anchored in transitional shelters, could be replicated in cities across the country at comparatively low cost, since it relies on existing pharmacy networks and remote coaching rather than new clinics. The trial also contributes a methodological template for studying cessation in transient populations, combining biochemical verification, extended follow-up, and outcome measures that respect participants’ full health context. For the roughly seven in ten homeless adults who smoke, most of whom express a desire to quit but lack access to sustained treatment, EXIT represents a rigorous test of whether the healthcare system can finally meet them where they are, for as long as quitting truly takes.

Subject of Research: A randomized controlled trial testing an extended pharmacy-linked tobacco cessation intervention with telephone coaching for adults experiencing homelessness.

Article Title: Extended Intervention for Tobacco Use (EXIT) for people experiencing homelessness: study protocol for a randomized controlled trial

Article References: Extended Intervention for Tobacco Use (EXIT) for people experiencing homelessness: study protocol for a randomized controlled trial. (n.d.). https://doi.org/10.1186/s13722-026-00720-z

Image Credits: AI Generated

DOI: 10.1186/s13722-026-00720-z

Keywords: tobacco cessation, homelessness, nicotine replacement therapy, randomized controlled trial, community pharmacies, telephone coaching, health inequity, smoking prevalence, transitional shelters, public health, clinical trial protocol, addiction science