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

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.

Invited Commentary: Use of Epidemiologic Methods to Guide Comprehensive and Equitable Approaches to Policy

Despite a dramatic reduction in the prevalence of commercial cigarette smoking in the United States, children are still commonly exposed to secondhand smoke (SHS), which is a cause of various pediatric health problems. Further, SHS exposure is patterned by race and class, exacting an inequitable toll on children from families with lesser social and economic advantage. In this issue of the Journal, Titus et al. (Am J Epidemiol. 2023;192(1):25-33) use natural experiment evaluation methods (difference-in-differences) to test whether the recently implemented US Department of Housing and Urban Development policy that forbade smoking in and around New York City Housing Authority buildings affected child respiratory health. The results from their work remind us that policies do not always impact outcomes as we might expect. Given that policy is one of the most potent tools for population health promotion, this work underlines the need for epidemiologists to engage in policy evaluation at all stages of the policy life cycle, in order to discover comprehensive approaches to policy development and implementation that prioritize equity and address structural racism.

Long-Term Trends in Secondhand Smoke Exposure in High-Rise Housing Serving Low-Income Residents in New York City: Three-Year Evaluation of a Federal Smoking Ban in Public Housing, 2018-2021

INTRODUCTION

In July 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies. We measured secondhand smoke (SHS) exposure immediately before, and repeatedly up to 36 months post-SFH policy implementation in a purposeful sample of 21 New York City (NYC) high-rise buildings (>15 floors): 10 NYC Housing Authority (NYCHA) buildings subject to the policy and 11 privately managed buildings in which most residents received housing vouchers (herein "Section 8").

AIMS AND METHODS

We invited participants from nonsmoking households (NYCHA n = 157, Section-8 n = 118) to enroll in a longitudinal air monitoring study, measuring (1) nicotine concentration with passive, bisulfate-coated filters, and (2) particulate matter (PM2.5) with low-cost particle sensors. We also measured nicotine concentrations and counted cigarette butts in common areas (n = 91 stairwells and hallways). We repeated air monitoring sessions in households and common areas every 6 months, totaling six post-policy sessions.

RESULTS

After 3 years, we observed larger declines in nicotine concentration in NYCHA hallways than in Section-8, [difference-in-difference (DID) = -1.92 µg/m3 (95% CI -2.98, -0.87), p = .001]. In stairwells, nicotine concentration declines were larger in NYCHA buildings, but the differences were not statistically significant [DID= -1.10 µg/m3 (95% CI -2.40, 0.18), p = .089]. In households, there was no differential change in nicotine concentration (p = .093) or in PM2.5 levels (p = .385).

CONCLUSIONS

Nicotine concentration reductions in NYCHA common areas over 3 years may be attributable to the SFH policy, reflecting its gradual implementation over this time.

IMPLICATIONS

Continued air monitoring over multiple years has demonstrated that SHS exposure may be declining more rapidly in NYCHA common areas as a result of SFH policy adherence. This may have positive implications for improved health outcomes among those living in public housing, but additional tracking of air quality and studies of health outcomes are needed. Ongoing efforts by NYCHA to integrate the SFH policy into wider healthier-homes initiatives may increase policy compliance.

The Effect of Floor Height on Secondhand Smoke Transfer in Multiunit Housing

Secondhand smoke (SHS) exposure remains a major public health concern in the United States. Homes have become the primary source of SHS exposure, with elevated risks for residents of multiunit housing. Though this differential risk is well-documented, little is known about whether SHS exposure varies by floor height. The aim of this study was to examine whether SHS accumulates in higher floors of multiunit housing. Using validated passive nicotine sampling monitors, we sampled air nicotine concentrations on multiple floors of 21 high-rise (>15 floors) buildings in New York City. Within the buildings, measurements were collected in three locations: non-smoking individual apartments, hallways and stairwells. Measurements were collected in two winter and two summer waves to account for potential seasonality effects. We analyzed the percent of filters with detectable nicotine and quantified nicotine concentration (µg/m3). Higher floor levels were positively associated with both airborne nicotine measures, with some variation by location and season observed. In winter, the trends were statistically significant in apartments (floors ≤7: 0.022 µg/m3; floors 8−14: 0.026 µg/m3; floors ≥15: 0.029 µg/m3; p = 0.011) and stairwells (floors ≤7: 0.18 µg/m3; floors 8−14: 0.19 µg/m3; floors ≥15: 0.59 µg/m3; p = 0.006). These findings can inform interventions to mitigate the SHS exposure of residents in multiunit housing.

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.

Randomised pilot trial of cash incentives for reducing paediatric asthmatic tobacco smoke exposures from maternal caregivers and members of their social network

BACKGROUND

The primary aim was to evaluate the efficacy of financial incentives for reducing paediatric tobacco smoke exposures (TSEs) through motivating cigarette usage reduction among low-income maternal caregivers and members of their social network.

DESIGN

Randomised control pilot trial over a 6-month study follow-up time period. The study was undertaken from May 2017 to -May 2018. Once monthly follow-up visits occurred over the 6-month study period.

SETTING

Baltimore City, Maryland, USA.

PARTICIPANTS

We grouped 135 participants into 45 triads (asthmatic child (2-12 years of age), maternal caregiver and social network member). Triads were assigned in a 1:1 allocation ratio. The maternal caregiver and social network members were active smokers and contributed to paediatric TSE.

INTERVENTIONS

Triads were randomised to receive either usual care (TSE education and quitline referrals) or usual care plus financial incentives. Cash incentives up to $1000 were earned by caregivers and designated social network participants. Incentives for either caregivers or social network participants were provided contingent on their individual reduction of tobacco usage measured by biomarkers of tobacco usage. Study visits occurred once a month during the 6-month trial.

MAIN OUTCOME MEASURES

The main outcome measure was mean change in monthly paediatric cotinine levels over 6 months of follow-up interval and was analysed on an intention-to-treat basis.

RESULTS

The mean change in monthly child cotinine values was not significantly different in the intervention cohort over the 6-month follow-up period, compared with the control group (p=0.098, CI -0.16 to 1.89). Trends in child cotinine could not be ascribed to caregivers or social network members. Despite decreasing mean monthly cotinine values, neither the intervention cohort's caregivers (difference in slope (control-intervention)=3.30 ng/mL/month, CI -7.72 to 1.13, p=0.144) or paired social network members (difference in slope (control-intervention)=-1.59 ng/mL/month, CI -3.57 to 6.74, p=0.546) had significantly different cotinine levels than counterparts in the control group.

CONCLUSIONS

Financial incentives directed at adult contributors to paediatric TSE did not decrease child cotinine levels.

TRIAL REGISTRATION NUMBER

NCT03099811.

Evaluation of Secondhand Smoke Exposure in New York City Public Housing After Implementation of the 2018 Federal Smoke-Free Housing Policy

IMPORTANCE

Secondhand smoke (SHS) exposure is associated with many health conditions in children and adults. Millions of individuals in the US are currently exposed to SHS in their homes.

OBJECTIVE

To investigate whether a federal ban on smoking in public housing settings was associated with a decrease in indoor SHS levels in New York City public housing developments 12 months after the policy's implementation.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study tracked indoor air quality longitudinally from April 2018 to September 2019 and used difference-in-differences analysis to examine SHS exposure before vs after implementation of the 2018 federal smoke-free housing (SFH) policy in 10 New York City Housing Authority (NYCHA) buildings vs 11 matched low-income buildings not subject to the SFH policy (ie, Section 8 buildings).

EXPOSURES

Federal SFH policy implementation, beginning July 30, 2018.

MAIN OUTCOMES AND MEASURES

Comparison of nicotine concentration levels from passive, bisulfate-coated filters before vs 12 months after implementation of the federal SFH policy. Secondary outcomes included changes in particulate matter less than 2.5 μm in diameter, measured with low-cost particle monitors, and counts of cigarette butts in common areas.

RESULTS

Air quality was measured repeatedly in a total of 153 NYCHA and 110 Section 8 nonsmoking households as well as in 91 stairwells and hallways. Before the SFH policy implementation, air nicotine was detectable in 19 of 20 stairwells (95.0%) in NYCHA buildings and 15 of 19 stairwells (78.9%) in Section 8 buildings (P = .19) and in 17 of 19 hallways (89.5%) in NYCHA buildings and 14 of 23 hallways (60.9%) in Section 8 buildings (P = .004). Nicotine was detected less frequently inside nonsmoking apartments overall (26 of 263 [9.9%]) but more frequently in NYCHA apartments (20 of 153 [13.1%]) than in Section 8 apartments (6 of 110 [5.5%]) (P = .04). One year after policy implementation, there was no differential change over time in nicotine concentrations measured in stairwells (DID, 0.03 μg/m3; 95% CI, -0.99 to 1.06 μg/m3) or inside nonsmoking households (DID, -0.04 μg/m3; 95% CI, -0.24 to 0.15 μg/m3). Larger decreases in nicotine concentration were found in NYCHA hallways than in Section 8 hallways (DID, -0.43 μg/m3; 95% CI, -1.26 to 0.40 μg/m3).

CONCLUSIONS AND RELEVANCE

The findings suggest that there was no differential change in SHS in NYCHA buildings 12 months after SFH policy implementation. Additional support may be needed to ensure adherence to SFH policies.

The Role of Environmental Controls in Managing Asthma in Lower-Income Urban Communities

Children living in lower-income urban communities are at much greater risk of developing asthma, going to the emergency department for an asthma attack and being hospitalized for asthma than children living in upper- and middle-income communities. For many asthmatic children living in urban communities, especially those with greater morbidity, the allergic pathway is important in the etiology of the disease. The stages of developing allergic disease can be divided into the onset of allergic sensitization, development of allergic disease and subsequent exacerbations, and it is useful to consider the relevance of interventions at each of these stages. Indoor allergens and environmental exposures are a major contributor to allergic disease, particularly among lower socioeconomic status, urban, minority communities. These exposures include allergens, environmental tobacco smoke, combustion by-products, and mold, all of which can play an important role in asthma progression as well as morbidity. These exposures are often not found in isolation and thus these concomitant exposures need to be considered when conducting environmental interventions. There have been numerous studies looking at both primary and tertiary prevention strategies and the impact on allergic sensitization and asthma with varied results. While the outcomes of these studies have been mixed, what has emerged is the need for tertiary interventions to be targeted to the individual and to reduce all relevant exposures to which an asthmatic child is exposed and sensitized. In addition, effective intervention strategies must also consider other social determinants of asthma morbidity impacting low socioeconomic, urban communities.

Secondhand smoke exposure in public and private high-rise multiunit housing serving low-income residents in New York City prior to federal smoking ban in public housing, 2018

BACKGROUND

Tobacco remains the leading cause of preventable death in the United States, with 41,000 deaths attributable to secondhand smoke (SHS) exposure. On July 30, 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies.

OBJECTIVES

Prior to SFH policy implementation, we measured self-reported and objective SHS incursions in a purposeful sample of 21 high-rise buildings (>15 floors) in New York City (NYC): 10 public housing and 11 private sector buildings where most residents receive federal housing subsidies (herein 'Section 8' buildings).

METHODS

We conducted a baseline telephone survey targeting all residents living on the 3rd floor or higher of selected buildings: NYC Housing Authority (NYCHA) residents were surveyed in April-July 2018 (n = 559), and residents in 'Section 8' buildings in August-November 2018 (n = 471). We invited non-smoking household participants to enroll into a longitudinal air monitoring study to track SHS exposure using: (1) nicotine concentration from passive, bisulfate-coated nicotine filters and (2) particulate matter (PM2.5) from low-cost particle monitors. SHS was measured for 7-days in non-smoking households (NYCHA n = 157, Section 8 n = 118 households) and in building common areas (n = 91 hallways and stairwells).

RESULTS

Smoking prevalence among residents in the 21 buildings was 15.5%. Two-thirds of residents reported seeing people smoke in common areas in the past year (67%) and 60% reported smelling smoke in their apartments coming from elsewhere. Most stairwells (88%) and hallways (74%) had detectable nicotine levels, but nicotine was detected in only 9.9% of non-smoking apartments. Substantial variation in nicotine and PM2.5 was observed between and within buildings; on average nicotine concentrations were higher in NYCHA apartments and hallways than in Section 8 buildings (p < 0.05), and NYCHA residents reported seeing smokers in common areas more frequently.

CONCLUSIONS

SFH policies may help in successfully reducing SHS exposure in public housing, but widespread pre-policy incursions suggest achieving SFH will be challenging.

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.

In-Home Secondhand Smoke Exposure Among Urban Children With Asthma: Contrasting Households With and Without Residential Smokers

CONTEXT

Secondhand smoke exposure (SHSe) affects up to half of all children in the United States. Many studies have identified factors associated with in-home SHSe, but few have contrasted these factors between households with and without residential smokers. In the latter case, exposure occurs from only external sources that enter the home, such as visitors or environmental incursion.

OBJECTIVE

Among children with SHSe at home, to examine demographic and psychosocial differences between households with and without residential smokers.

DESIGN

Baseline analysis of an observational cohort.

SETTING

Baltimore City, Maryland.

PARTICIPANTS

A total of 157 children with asthma, aged 5 to 12 years.

MEASURES

At-home airborne nicotine, caregiver-reported depression, asthma-related quality of life, functional social support, and demographics. Univariable comparisons were performed between SHS-exposed households with and without residential smokers. Multivariable logistic regression models were fit to examine associations between measured factors and absence of residential smokers.

RESULTS

Children (78.3%) had at-home SHSe. Of these, 40.7% lived in households without residential smokers. Compared with households with residential smokers, these caregivers endorsed stronger beliefs in SHS harms and also worse functional social support and asthma-related stress, despite no differences in asthma morbidity. In adjusted models, SHS-exposed children with caregivers in the lowest tertile of functional social support (adjusted odds ratio, 3.50; 95% confidence interval, 1.12-10.99), asthma-related quality of life (2.90; 1.06-7.95), and those living alone (5.28; 1.26-22.15) had at least twice higher odds of having exclusively external SHSe than the highest tertile (P trends < .05).

CONCLUSIONS

In-home SHS exposure remains alarmingly high in urban environments. However, a substantial proportion of this exposure appears to be occurring only from external sources that enter the home. Caregivers in these homes had higher desire but lower agency to avoid SHSe, driven by lack of functional support and physical isolation. Public policies targeting these factors may help remediate exposure in this especially vulnerable population.