Changes in Tobacco Smoke Exposure following the Institution of a Smoke-Free Policy in the Boston Housing Authority

A Matched Analysis of the Association Between Federally Mandated Smoke-Free Housing Policies and Health Outcomes Among Medicaid-Enrolled Children in Subsidized Housing, New York City, 2015-2019

Smoke-free housing policies are intended to reduce the deleterious health effects of secondhand smoke exposure, but there is limited evidence regarding their health impacts. We examined associations between implementation of a federal smoke-free housing rule by the New York City Housing Authority (NYCHA) and pediatric Medicaid claims for asthma, lower respiratory tract infections, and upper respiratory tract infections in the early post-policy intervention period. We used geocoded address data to match children living in tax lots with NYCHA buildings (exposed to the policy) to children living in lots with other subsidized housing (unexposed to the policy). We constructed longitudinal difference-in-differences models to assess relative changes in monthly rates of claims between November 1, 2015, and December 31, 2019 (the policy was introduced on July 30, 2018). We also examined effect modification by baseline age group (≤2, 3-6, or 7-15 years). In New York City, introduction of a smoke-free policy was not associated with lower rates of Medicaid claims for any outcomes in the early postpolicy period. Exposure to the smoke-free policy was associated with slightly higher than expected rates of outpatient upper respiratory tract infection claims (incidence rate ratio = 1.05, 95% confidence interval: 1.01, 1.08), a result most pronounced among children aged 3-6 years. Ongoing monitoring is essential to understanding long-term health impacts of smoke-free housing policies.

Peer mentoring for smoking cessation in public housing: A mixed-methods study

Introduction

Tobacco use disproportionately affects low-income African American communities. The recent public housing smoke-free policy has increased the demand for effective smoking cessation services and programs in such settings.

Methods

This mixed-method pilot study explored feasibility and potential impact of a peer-mentoring program for smoking cessation in a public housing unit. The quantitative study used a quasi-experimental design while qualitative data were collected via focus group discussions with peer mentors and participants. Three residents of the public housing complex were trained as peer mentors. Each peer mentor recruited up to 10 smokers in the residence and provided them individual support for 12 weeks. All participants were offered Nicotine Replacement Therapy (NRT). A follow-up investigation was conducted 3 months after completion of the 12-week intervention. At baseline and follow-up, the participants' smoking status was measured using self-report and was verified using exhaled carbon monoxide (eCO) monitoring.

Results

The intervention group was composed of 30 current smokers who received the peer-mentoring intervention. The control group was composed of 14 individuals. Overall mean eCO levels dropped from 26 ppm (SD 19.0) at baseline to 12 (SD 6.0) at follow-up (P < 0.01). Participants who were enrolled in our program were more likely to have non-smoking eCO levels (<7 ppm) at follow-up (23.3%) compared to those who did not enroll (14.3%).

Conclusion

Our program is feasible for low-income predominantly African American communities. Using peers as mentors may be helpful in providing services for hard-to-reach populations. Given the non-randomized design of our study, randomized trials are needed to test the efficacy of our program in the future.

Changes in Reported Secondhand Smoke Incursions and Smoking Behavior after Implementation of a Federal Smoke-Free Rule in New York State Federally Subsidized Public Housing

This study assessed changes in smoking behavior and secondhand smoke (SHS) exposure after implementation of the U.S. Department of Housing and Urban Development (HUD) rule prohibiting the use of cigarettes, cigars, pipes, and waterpipes in all federally subsidized public housing, including within residential units (apartments). Using quantitative data from a repeated cross-sectional mail survey of New York State residents of five public housing authorities (N = 761 at Wave 1, N = 649 at Wave 2), we found evidence of policy compliance (99% decrease in odds of self-reported smoking in units, OR = 0.01, p < 0.01, CI: 0.00−0.16), reduced SHS incursions (77% decrease in odds of smelling smoke within developments, OR = 0.23, p < 0.01, CI: 0.13−0.44), and lower reported smoking rates in July 2018 (9.5%, down from 16.8%), 10 months after implementation of the rule. Despite evident success, one-fifth of residents reported smelling smoke inside their apartment at least a few times per week. This study provides insights into how the policy was implemented in selected New York public housing authorities, offers evidence of policy-intended effects, and highlights challenges to consistent and impactful policy implementation.

Implementing the Federal Smoke-Free Public Housing Policy in New York City: Understanding Challenges and Opportunities for Improving Policy Impact

In 2018, the U.S. Department of Housing and Urban Development required public housing authorities to implement a smoke-free housing (SFH) policy that included individual apartments. We analyzed the policy implementation process in the New York City Public Housing Authority (NYCHA). From June-November 2019, we conducted 9 focus groups with 64 NYCHA residents (smokers and nonsmokers), 8 key informant interviews with NYCHA staff and resident association leaders, and repeated surveys with a cohort of 130 nonsmoking households pre- and 12-month post policy. One year post policy implementation, participants reported widespread smoking violations and multi-level factors impeding policy implementation. These included the shared belief among residents and staff that the policy overreached by "telling people what to do in their own apartments". This hindered compliance and enforcement efforts. Inconsistent enforcement of illegal marijuana use, staff smoking violations, and a lack of accountability for other pressing housing issues created the perception that smokers were being unfairly targeted, as did the lack of smoking cessation resources. Resident support for the policy remained unchanged but satisfaction with enforcement declined (60.1% vs. 48.8%, p = 0.047). We identified multilevel contextual factors that are influencing SFH policy implementation. Findings can inform the design of strategies to optimize policy implementation.

A qualitative study of the process of adoption, implementation and enforcement of smoke-free policies in privately-owned affordable housing

Background

Household smoke-free home rules cannot fully protect nonsmokers from secondhand smoke (SHS) if they live in multi-unit housing (MUH). Instead, property-level smoke-free policies are needed to prevent SHS incursion into apartment units and to keep common areas smoke-free. Smoke-free policies are usually at the discretion of property management companies and owners within the context of market-rate and privately-owned affordable housing in the U.S.

Methods

Semi-structured interviews on the policy development, implementation and enforcement experiences of 21 different privately-owned affordable housing management companies were conducted with representatives from properties in North Carolina and Georgia who had established smoke-free policies before 2016.

Results

The decision to adopt was typically made by corporate leadership, board members, owners or property managers, with relatively little resident input. Policy details were influenced by property layout, perceptions of how best to facilitate compliance and enforcement, and cost of creating a designated smoking area. Policies were implemented through inclusion in leases, lease addenda or house rules with 6 months’ notice most common. Participants thought having a written policy, the norms and culture of the housing community, public norms for smoke-free environments, and resident awareness of the rules and their consequences, aided with compliance. Violations were identified through routine inspections of units and resident reporting. Resident denial and efforts to hide smoking were shared as challenges to enforcement, along with a perception that concrete evidence would be needed in eviction court and that simply the smell of SHS was insufficient evidence of violation. Over half had terminated leases or evicted residents due to violations of the smoke-free policy. The most common benefits cited were reduced turnover cost and time, and lower vacancy rates.

Conclusions

Understanding the smoke-free policy process in privately-owned affordable housing can help practitioners encourage policies within subsidized housing contexts. The study identified salient benefits (e.g., reduced cost, time, and vacancies) that can be highlighted when encouraging MUH partners to adopt policies. Additionally, study findings provide guidance on what to consider when designing smoke-free policies (e.g., layout, costs), and provide insights into how to enhance compliance (e.g., resident awareness) and manage enforcement (e.g., routine inspections).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7404-y) contains supplementary material, which is available to authorized users.

Perceived barriers to quitting cigarettes among hospitalized smokers with substance use disorders: A mixed methods study

AIMS

Smoking cessation may promote long-term recovery in patients with substance use disorders (SUD). Yet smoking rates remain alarmingly high in this population. Using a sequential explanatory mixed methods approach, we examined smoking rates among hospitalized patients with SUD at a large safety-net hospital, and then characterized factors associated with smoking behaviors both quantitatively and qualitatively.

METHOD

We abstracted data from all hospital admissions (7/2016-6/2017) and determined demographics, substance use type, and other characteristics associated with cigarette use among those with SUD. We then conducted semi-structured qualitative interviews with 20 hospitalized SUD smokers. We analyzed transcripts to characterize factors that affect patients' smoking habits, focusing on the constructs of the Health Belief Model.

RESULTS

The prevalence of cigarette smoking among hospitalized smokers with SUD was three times higher than those without SUD. Qualitative analyses showed that patients perceived that smoking cigarettes was a less serious concern than other substances. Some patients feared that quitting cigarettes could negatively impact their recovery and perceived that clinicians do not prioritize treating tobacco dependence. Almost all patients with heroin use disorder described how cigarette use potentiated their heroin high. Many SUD patients are turning to vaping and e-cigarettes to quit smoking.

CONCLUSION

Hospitalized patients with SUD have disproportionately high smoking rates and perceive multiple barriers to quitting cigarettes. When designing and implementing smoking cessation interventions for hospitalized patients with SUD, policymakers should understand and take into account how patients with SUD perceive smoking-related health risks and how that influences their decision to quit smoking.

A protocol for measuring the impact of a smoke-free housing policy on indoor tobacco smoke exposure

BACKGROUND

Tobacco remains a leading cause of preventable death in the U.S., responsible for more than 440,000 deaths each year. Approximately 10% of these deaths are attributable to exposure of non-smokers to secondhand smoke (SHS). Residents living in public multi-unit housing (MUH) are at excess risk for SHS exposure compared to the general population. On November 30, 2016, the U.S. Department of Housing and Urban Development (HUD) passed a rule requiring all public housing agencies to implement smoke-free housing (SFH) policies in their housing developments by July 30, 2018.

METHODS

As part of a larger natural experiment study, we designed a protocol to evaluate indoor SHS levels before and after policy implementation through collection of repeat indoor air samples in non-smoking apartments and common areas of select high-rise NYCHA buildings subject to the HUD SFH rule, and also from socio-demographically matched private-sector high-rise control buildings not subject to the rule. A baseline telephone survey was conducted in all selected buildings to facilitate rapid recruitment into the longitudinal study and assess smoking prevalence, behaviors, and attitudes regarding the SFH policy prior to implementation. Data collection began in early 2018 and will continue through 2021.

DISCUSSION

The baseline survey was completed by 559 NYCHA residents and 471 comparison building residents (response rates, 35, and 32%, respectively). Smoking prevalence was comparable between study arms (15.7% among NYCHA residents and 15.2% among comparison residents). The majority of residents reported supporting a building-wide smoke-free policy (63.0 and 59.9%, respectively). We enrolled 157 NYCHA and 118 comparison non-smoking households into the longitudinal air monitoring study and performed air monitoring in common areas. Follow up surveys and air monitoring in participant households occur every 6 months for 2.5 years. Capitalizing on the opportunity of this federal policy rollout, the large and diverse public housing population in NYC, and robust municipal data sources, this study offers a unique opportunity to evaluate the policy's direct impacts on SHS exposure. Methods in this protocol can inform similar SFH policy evaluations elsewhere.

Implementation and enforcement of smoke-free policies in public housing

Smoke-free policies such as those required by the US Department of Housing and Urban Development have the potential to reduce persistent income-related disparities in secondhand smoke exposure. To understand the implementation and enforcement process, as well as barriers and facilitators to compliance and enforcement, we conducted semi-structured interviews (n=37) with representatives from 23 Public Housing Authorities (PHAs) with some level of smoking restriction in place, along with residents from 14 of these PHAs, from January to August 2016. Residents were typically notified of the new policy through group meetings, new resident orientations and/or one-on-one discussions during lease renewal or annual recertification. Timing of implementation varied, with advanced notice of 6 months or a year most common. Enforcement typically involved a series of verbal and/or written warnings, followed by written notice of lease violation, and eventual notice of lease termination and/or eviction. Challenges in enforcement were generally classified as monitoring difficulties or legal concerns. Characterizing current practices (e.g. advance notice, clear communication of escalating consequences, cessation support and concrete evidence of violation) from early adopters sets the stage for identifying best practices and helps to ensure successful and fair implementation of smoke-free policies in subsidized housing.

Public Support for Smoke-Free Section 8 Public Housing

The U.S. Department of Housing and Urban Development (HUD) recently issued rules requiring that federally funded authorities administering public housing must have smoke-free policies. Importantly, this requirement does not extend to Section 8 housing. Under the Section 8 program, public housing vouchers provide subsidies for private rental housing to low-income residents. This study examines support for smoke-free policy options in Section 8 housing. Using a nationally representative survey of adults, we asked 3,070 respondents to agree or disagree with two potential policies. The majority (71%) supported prohibiting indoor smoking everywhere inside buildings that have Section 8 housing units. Alternatively, respondents were less supportive (38%) of a policy to prohibit smoking only inside units with Section 8 subsidies, and allowing smoking in nonsubsidized units. Prohibiting smoking in all units in multiunit housing (MUH) buildings would help protect the health of both the 2.2 million households who receive Section 8 subsidies and their neighbors.

Smoke-Free Multi-unit Housing Policies Show Promise in Reducing Secondhand Smoke Exposure Among Racially and Ethnically Diverse, Low-Income Seniors

Secondhand smoke (SHS) exposure is a public health issue for residents of multi-unit housing (MUH) properties. We evaluated the impact of smoke-free policy implementation on reported SHS exposure among racially, ethnically diverse seniors living in low-income MUH properties. In Spring 2013 and Summer 2014, we surveyed residents (n = 960) at 15 MUH properties in Broward and Miami-Dade Counties, Florida. The percentage of residents reporting SHS exposure within their apartments from elsewhere in or around their building decreased from 31.1 %, before policy implementation, to 23.6 % at follow-up (p = 0.02). In multivariate analysis of non-smoking residents after policy implementation, residents who reported having one or more comorbidities were two times more likely to report SHS exposure (aOR 2.23, 95 % CI 1.12-4.40). Considering the vulnerability of low-income seniors to SHS exposure, our findings are relevant to residents, property owners/managers, and public health professionals making decisions about smoke-free policies for MUH properties in which seniors reside.

Tobacco-Smoke Incursions and Satisfaction Among Residents With Children in Multiunit Housing, United States, 2013

OBJECTIVES

Residents of multiunit housing can be exposed to tobacco smoke even if they do not permit smoking in their homes. Although even low levels of tobacco smoke exposure can cause health problems for children and adults, some landlords are reluctant to ban smoking for fear of decreased occupancy rates or tenant satisfaction. The objective of this study was to assess the impact of tobacco smoke-free policies and tobacco-smoke incursions on housing satisfaction in multiunit housing residences with children.

METHODS

In 2013, 3696 randomly sampled US adult multiunit housing dwellers were invited to participate in a survey, and 3253 (88%) participated. Of these, 3128 responded to the question about having a child in the home, and 835 (27%) reported having a child in the home. We collected data on demographic characteristics, tobacco-smoke incursions, knowledge and attitudes about smoking policies, and housing satisfaction for this sample of 835 residents.

RESULTS

Of the 827 residents who responded to the question, 755 (91.3%) agreed that tenants have a right to live in a tobacco smoke-free building. Although 672 of 835 (80.5%) residents were not cigarette smokers, most lived where smoking was permitted in the units (n = 463, 56.9%) or on the property (n = 571, 70.5%). Of 580 non-cigarette smoking residents who lived where no one had smoked cigarettes in the home for the past 3 months, 144 (25.2%) reported a recent tobacco-smoke incursion. Of these 144 residents, 143 (99%) were bothered. Few (36/143, 25.2%) complained to the landlord. Reasons for not complaining were reluctance to upset neighbors or concern about retaliation. Tobacco-smoke incursions and housing/landlord satisfaction were inversely related ( P < .05).

CONCLUSION

Multiunit housing residents living with children in the United States strongly support smoke-free multiunit housing.

Secondhand Smoke Exposure and Smoke-free Policy in Philadelphia Public Housing

OBJECTIVES

Multi-unit housing environments remain significant sources of secondhand smoke (SHS) exposure, especially for vulnerable populations in subsidized housing. In Philadelphia, the largest US housing authority to implement smoke-free policies, we measured baseline resident smoking-related behaviors and attitudes, and longitudinal exposures to airborne nicotine, during policy development and implementation.

METHODS

In 4 communities, we collected data in 2013, 2014, and 2016, before and after introduction of comprehensive smoke-free policies, interviewing persons in 172 households, and monitoring air-borne nicotine in non-smoking homes and public areas. Average nicotine level differences across years were estimated with multi-level models.

RESULTS

Fifty-six percent of respondents smoked. Only 37% of households were smoke-free, with another 41% restricting smoking by area or time of day. The number of locations with detectable nicotine did not differ before and after policy implementation, with approximately 20% of non-smoking homes and 70%-80% of public areas having detectable nicotine. However, public area nicotine levels were lower in 2016, after policy implementation, than in 2013 and 2014 (-0.19 μg/m3, p = .03).

CONCLUSIONS

Findings suggest that initial policy implementation was associated with reduced SHS exposure in Philadelphia. As HUD strengthens smoke-free policies, SHS monitoring can be useful to educate stakeholders and build support for policy enforcement.

Delivering on the Promise of Smoke-Free Public Housing

On November 30, 2016, the US Department of Housing and Urban Development (HUD) published a final rule mandating that public housing authorities it supports prohibit all smoking on their residential premises, including within residents' apartments. The primary rationale for this action was to protect nonsmoking residents from the harms of tobacco smoke exposure. Although the harms of secondhand smoke are clear and the potential for reducing nonsmoking residents' exposure is real, it will be no simple matter to successfully implement the policy requirements set down by HUD. Some challenges to policy implementation will apply to all public housing authorities, and others will be unique to specific settings. By being aware of the benefits of smoke-free public housing as well as the challenges inherent in complying with HUD's rule, public housing authorities stand the best chance of fulfilling the potential of this major policy initiative to significantly improve public health in a vulnerable population.