Attitudes,Experiences, and Acceptance of Smoke-Free Policies Among US Multiunit Housing Residents

We assessed factors related to smoke-free policies among a cross-sectional, nationally representative, random-digit-dial sample (landline and cell phone) of US multiunit housing residents (n = 418). Overall, 29% reported living in smoke-free buildings, while 79% reported voluntary smoke-free home rules. Among those with smoke-free home rules, 44% reported secondhand smoke incursions in their unit. Among all respondents, 56% supported smoke-free building policy implementation. These findings suggest that smoke-free building policies are needed to protect multiunit housing residents from secondhand smoke in their homes.Secondhand smoke (SHS) contains hundreds of toxic or carcinogenic compounds and can cause significant morbidity and mortality among nonsmoking children and adults.1–3 Currently, there is a growing interest in adopting smoke-free policies in private settings, including multiunit housing (MUH). The home represents a major source of SHS exposure for many individuals,2,4–6 and MUH residents are particularly susceptible to SHS incursions from nearby units and shared areas.6–8 This cross-sectional study evaluated attitudes, experiences, and acceptance of smoke-free home rules and building policies among a nationally representative sample of US MUH residents.     

Evaluating the Implementation Process of a Citywide Smoke-Free Multiunit Housing Ordinance: Insights from Community Stakeholders

We evaluated the implementation process of Richmond, California’s citywide smoke-free multiunit housing ordinance. We conducted semistructured focus groups with multiunit housing tenants, owners, and managers. Residents understood the harms of secondhand smoke but lacked accurate information about the ordinance and questioned its enforceability. They shared concerns that the city lacked cessation resources for smokers wishing to quit because of the ordinance. To increase compliance with the ordinance, tenants, owners, and managers need accurate information.Implementing smoke-free multiunit housing (MUH) policies is the most effective way to protect MUH residents from secondhand smoke exposure.1,2 We have discussed how MUH tenants, owners, and managers view the implementation of Richmond, California’s citywide smoke-free MUH ordinance and potential barriers to its equitable implementation across the city’s diverse neighborhoods.The majority (78%) of Richmond’s 106 516 residents are ethnic minorities; 38% of Richmond’s population live in MUH residences.3,4 In 2009, Richmond passed an ordinance to prohibit the smoking of any tobacco product or marijuana in residential dwellings containing 2 or more units; it was fully implemented in 2011.5     

Support for No-Smoking Policies Among Residents of Public Multiunit Housing Differs by Smoking Status

We compared perceptions of smoking and non-smoking Tacoma, WA multiunit public housing residents regarding smoke-free policies and in-home smoking rules. Two-hundred-twenty-nine completed surveys (~16 % of units) of a modified version of the CDC’s multiunit housing resident survey were analyzed. Smokers differed significantly (p < 0.05) from non-smokers with respect to agreement with policies that would ban smoking in homes (41 % of smokers and 82 % of non-smokers strongly agreed or agreed), in common indoor areas (74 % of smokers and 82 % of non-smokers strongly agreed or agreed), and for outdoor areas (38 % of smokers and 68 % of non-smokers strongly agreed or agreed). For in-home smoking rules, smokers and non-smokers again differed significantly (p < 0.05) with 53 % of smokers and 90 % of non-smokers not allowing smoking in their homes. Twenty-five percent of residents reported smelling secondhand smoke that infiltrated their residence from the outside on a daily basis. The most notable findings are that more than 50 % of smokers do not allow smoking in their homes and that more than 50 % of smokers are supportive of or neutral with respect to smoke-free policies for one’s home. This suggests that implementation of smoke-free policies may not greatly impact vacancy rates even in populations with high rates of smoking (37 % in this study).     

Peer Reviewed: The Acceptability of Comprehensive Smoke-Free Policies to Low-Income Tenants in Subsidized Housing

Our objective was to evaluate the acceptability of a comprehensive smoke-free policy among low-income tenants in a group of subsidized, multiunit buildings. We conducted a mixed-methods evaluation that included questionnaires mailed to 839 tenants and follow-up telephone interviews with 23 tenants who were current, former, and never smokers. Most never and former smokers supported the policy, citing improved health, fire safety, and building cleanliness; most current smokers disliked the policy and did not follow it. Messages focusing on shared community-level concerns, accompanied by smoking cessation resources, may support the transition to smoke-free policies in subsidized housing.     

Peer Reviewed: Moving Multiunit Housing Providers Toward Adoption of Smoke-Free Policies

Background

Tenants in multiunit housing are at elevated risk for exposure to secondhand smoke at home because of smoke migration from other units.

Community Context

In 2004, tobacco control advocates in the Portland, Oregon, metropolitan area began to address this issue by launching a campaign to work with landlord and tenant advocates, private- and public-sector property managers, and other housing stakeholders to encourage smoke-free policies in multiunit housing.

Methods

We outline the 6-year campaign that moved local housing providers toward adopting no-smoking policies. We used the stages of change model, which matches potential messages or interventions to a smoker''s readiness to quit smoking.

Outcome

The campaign resulted in Oregon''s largest private property management company and its largest public housing authority adopting no-smoking policies for their properties and a 29% increase in the availability of smoke-free rental units in the Portland-Vancouver metro area from 2006 through 2009.

Interpretation

We learned the importance of building partnerships with public and private stakeholders, collecting local data to shape educational messages, and emphasizing to landlords the business case, not the public health rationale, for smoke-free housing.     

Comprehensive Smoke-Free Policies: A Tool for Improving Preconception Health?

Lower income women are at higher risk for preconception and prenatal smoking, are less likely to spontaneously quit smoking during pregnancy, and have higher prenatal relapse rates than women in higher income groups. Policies prohibiting tobacco smoking in public places are intended to reduce exposure to secondhand smoke; additionally, since these policies promote a smoke-free norm, there have been associations between smoke-free policies and reduced smoking prevalence. Given the public health burden of smoking, particularly among women who become pregnant, our objective was to assess the impact of smoke-free policies on the odds of preconception smoking among low-income women. We estimated the odds of preconception smoking among low-income women in Ohio between 2002 and 2009 using data from repeated cross-sectional samples of women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). A logistic spline regression was applied fitting a knot at the point of enforcement of the Ohio Smoke-free Workplace Act to evaluate whether this policy was associated with changes in the odds of smoking. After adjusting for individual- and environmental-level factors, the Ohio Smoke-free Workplace Act was associated with a small, but statistically significant reduction in the odds of preconception smoking in WIC participants. Comprehensive smoke-free policies prohibiting smoking in public places and workplaces may also be associated with reductions in smoking among low-income women. This type of policy or environmental change strategy may promote a tobacco-free norm and improve preconception health among a population at risk for smoking.     

Secondhand Smoke Exposure and Smoke-Free Policy Support Among Public Housing Authority Residents in Rural and Tribal Settings

Previous research has shown that multi-unit housing (MUH) residents are at risk of secondhand smoke (SHS) exposure, which can transfer between units. The purpose of this study was to determine SHS exposure and examine attitudes towards smoking policies among public housing authority (PHA) residents in rural and tribal settings. A self-administered questionnaire was completed by 895 adult tenants (41 % response rate) living in PHA multiunit buildings in Montana in 2013. Our primary outcome was tenant support of smoke-free policies; our secondary outcome was exacerbation of child asthma symptoms due to SHS exposure. In 2014, we used multiple logistic regression models to test associations between independent variables and outcomes of interest. The majority (80.6 %) of respondents supported having a smoke-free policy in their building, with support being significantly higher among nonsmokers [adjusted odds ratio (aOR) 4.2, 95 % confidence interval (CI) 1.5–11.6] and among residents living with children (aOR 2.9, 95 % CI 1.3–6.2). Tribal residents were as likely to support smoke-free policies as non-tribal residents (aOR 1.4; 95 % CI 0.5–4.0). Over half (56.5 %) of respondents reported SHS exposure in their home; residents in a building with no smoke-free policy in place were significantly more likely to report exposure (aOR 3.5, 95 % CI 2.2–5.5). SHS exposure was not significantly associated with asthma symptoms. There is a significant reduction in exposure to SHS in facilities with smoke-free policies and there is strong support for such policies by both tribal and non-tribal MUH residents. Opportunities exist for smoke-free policy initiatives in rural and tribal settings.     

Estimates of smoking-related property costs in California multiunit housing

We systematically evaluated smoking-related costs in multiunit housing. From 2008 to 2009, we surveyed California multiunit housing owners or managers on their past-year smoking-related costs and smoke-free policies. A total of 27.1% of respondents had incurred smoking-related costs (mean $4935), and 33.5% reported complete smoke-free policies, which lowered the likelihood of incurring smoking-related costs. Implementing statewide complete smoke-free policies may save multiunit housing property owners $ 18,094,254 annually.     

Tobacco Smoke Incursions in Multiunit Housing

Objectives. We sought to describe the prevalence of secondhand tobacco smoke incursions reported by multiunit housing (MUH) residents, pinpoint factors associated with exposure, and determine whether smoke-free building policy was associated with prevalence of reported tobacco smoke incursions.Methods. Data are from a 2011 nationally representative dual-frame survey (random-digit-dial and Internet panels) of US adults aged 18 years and older. Individuals who lived in MUH and who reported no smoking in their homes for the past 3 months, whether or not they reported being smokers themselves, were included in this study. Incursions were defined as smelling tobacco smoke in their building or unit.Results. Of 562 respondents, 29.5% reported smoke incursions in their buildings. Of these, 16% reported incursions in their own unit, 36.2% of which occurred at least weekly. Government-subsidized housing and partial smoke-free policies were associated with a higher likelihood of reporting smoke incursions.Conclusions. Many residents of multiunit housing are exposed to tobacco smoke in their units and buildings. Partial smoke-free policies do not appear to protect residents and might increase the likelihood of incursions in residents’ individual units.The United States Surgeon General has extensively documented the harmful effects of smoking tobacco among adults1 and the negative effects of secondhand tobacco smoke (SHS) on both adults and children.2 Even brief exposures to SHS can result in sustained vascular injury3 and changes in endothelial function.4 In addition, studies have shown that very low levels of SHS exposure are associated with cognitive deficits5 and decreased antioxidant levels6 in children. Young children breathe faster than adults,7 have a tendency to mouth surfaces and objects,8 and may spend more of their time in the home,9 especially in places where outdoor activities might be perceived as unsafe.10 These all may increase their potential for tobacco smoke inhalation and ingestion.11 In a recent US Centers for Disease Control and Prevention study, 54% of children aged 3 to 11 years had biological evidence of SHS exposure; however, only 18% had a household member who smoked in the home,12 suggesting the significant contribution of other sources of tobacco smoke.Approximately 25% of US residents live in multiunit housing,13 where air circulation patterns facilitate the spread of tobacco smoke from unit to unit.14 Tobacco smoke permeates housing complexes through air ducts, cracks in the floor and walls, stairwells, hallways, elevator shafts, electrical lines, and open windows.15 US residents spend about 69% of their time in private residences16; thus, drifting smoke from other residences may provide a significant source of exposure for those in nonsmoking homes. A study of real-time SHS transfer in multiunit housing (MUH) between smoke-free and smoke-permitting units demonstrated incursions into both smoke-free units and adjacent hallways15; another study of low-income MUH in Boston, Massachusetts, demonstrated SHS contamination in homes where residents reported that neither household members nor visitors smoked.17 In an analysis of national data, cotinine levels for children living in apartments were 45% higher than for those living in detached homes.18 These studies suggest a significant role for SHS exposure in MUH. Recently, studies have begun to examine the prevalence of incursions in MUH. The first major national study discovered that 29% of US multiunit housing residents lived in a smoke-free building, and of those who did not but had voluntary smoke-free home rules, 44% reported incursions in their unit.19 In New York State, 46.2% of residents of MUH reported experiencing an incursion in their home, and more than 9% experienced incursions daily.20 Other local studies have shown similar rates of SHS incursions in MUH.21,22In 2012, the US Department of Housing and Urban Development (HUD) reissued recommendations that strongly encouraged all of their housing units go smoke-free23; however, this is not yet a requirement, and policies regulating SHS exposure in personal living spaces remain limited.22 Estimates show that although most residents of MUH would prefer to live in a smoke-free environment,20,22 most MUH developments do not have comprehensive smoke-free policies.22 We reported on a national survey of MUH residents to examine factors associated with tobacco smoke incursions. We hypothesized that type of smoke-free building policy (comprehensive, partial, or none) would be associated with prevalence of reported SHS incursions.     

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.     

Vital Signs: Disparities in Nonsmokers’ Exposure to Secondhand Smoke — United States, 1999–2012

Background

Exposure to secondhand smoke (SHS) from burning tobacco causes disease and death in nonsmoking children and adults. No risk-free level of SHS exposure exists.

Methods

National Health and Nutrition Examination Survey (NHANES) data from 1999–2012 were used to examine SHS exposure among the nonsmoking population aged ≥3 years. SHS exposure among nonsmokers was defined as a serum cotinine level (a metabolite of nicotine) of 0.05–10 ng/mL. SHS exposure was assessed overall and by age, sex, race/ethnicity, poverty level, education, and whether the respondent owned or rented their housing.

Results

Prevalence of SHS exposure in nonsmokers declined from 52.5% during 1999–2000 to 25.3% during 2011–2012. During this period, declines were observed for all population subgroups, but disparities exist. During 2011–2012, SHS was highest among: children aged 3–11 years (40.6%), non-Hispanic blacks (46.8%), persons living below the poverty level (43.2%), and persons living in rental housing (36.8%). Among children aged 3–11 years, 67.9% of non-Hispanic blacks were exposed to SHS compared with 37.2% of non-Hispanic whites and 29.9% of Mexican Americans.

Conclusion

Overall, SHS exposure in the United States has been reduced by half since 1999–2000. However, 58 million persons were still exposed to SHS during 2011–2012, and exposure remains higher among children, non-Hispanic blacks, those living in poverty, and those who rent their housing.

Implications for Public Health Practice

Eliminating smoking in indoor spaces fully protects nonsmokers from SHS exposure; separating smokers from nonsmokers, cleaning the air and ventilating buildings cannot completely eliminate exposure. Continued efforts to promote implementation of comprehensive statewide laws prohibiting smoking in workplaces and public places, smoke-free policies in multiunit housing, and voluntary smoke-free home and vehicle rules are critical to protect nonsmokers from this preventable health hazard in the places they live, work, and gather.     

Local Housing Choice Voucher Distribution Policies Impact Healthcare Utilization: a Randomized Natural Experiment

While associations between obtaining affordable housing and improved health care are well documented, insufficient funding often forces housing authorities to prioritize limited housing vouchers to specific populations. We assessed the impact of obtaining housing on health care utilization at two urban housing authorities with different distribution policies: Housing Authority A prioritized seniors and people with disabilities, while Housing Authority B prioritized medically complex individuals and families with school-aged children. Both housing authorities used random selection to distribute vouchers, allowing us to conduct a randomized natural experiment of cases and waitlisted controls. No significant demographic differences were present between those receiving vouchers and waitlisted controls. Housing Authority A vouchers were associated with increased outpatient visits (OR = 1.19; P = 0.051). Housing Authority B vouchers decreased the likelihood of emergency department visits (OR = 0.61; P = 0.042). This study provides evidence that, while obtaining housing can result in better health care outcomes overall, local prioritization policies can influence that impact.     

‘If I pay rent,I’m gonna smoke’: Insights on the social contract of smokefree housing policy in affordable housing settings

Smoke-free housing policy in multi-unit housing has emerged as a promising tobacco control initiative, yet full compliance remains elusive and is a critical impediment to policy effectiveness. There is a gap in existing research on potential factors preventing optimal smoke-free policy adoption and corresponding solutions. Using qualitative and quantitative data from resident surveys (N = 115) as well as key informant interviews, a focus group, and observational fieldwork, this study 1) assesses smoking behaviors and experience with secondhand smoke in buildings after adoption of a smoke-free policy; 2) examines resident and property management perceptions of the policy; and 3) identifies socioecological factors that influence the policy's effectiveness in affordable housing settings in New York City. Findings indicate that residents view smoking regulations within the context of broader relationships with the housing provider and other residents. We argue that these “social contracts” strongly influence the effectiveness of smoke-free housing policies and must be acknowledged to maximize compliance.     

Association of Campus Tobacco Policies With Secondhand Smoke Exposure,Intention to Smoke on Campus,and Attitudes About Outdoor Smoking Restrictions

College campus tobacco-free policies are an emerging trend. Between September 2013 and May 2014, we surveyed 1309 college students at 8 public 4-year institutions across California with a range of policies (smoke-free indoors only, designated outdoor smoking areas, smoke-free, and tobacco-free).Stronger policies were associated with fewer students reporting exposure to secondhand smoke or seeing someone smoke on campus. On tobacco-free college campuses, fewer students smoked and reported intention to smoke on campus. Strong majorities of students supported outdoor smoking restrictions across all policy types.Comprehensive tobacco-free policies are effective in reducing exposure to smoking and intention to smoke on campus.Exposure to tobacco smoke harms nearly every organ of the body.1 Young adults smoke at rates higher than any other age group,2 likely in part because the tobacco industry aggressively markets to young adults3 as the youngest age group that they can legally target. Between 2001 and 2011, undergraduate enrollment increased 32% from 13.7 million to 18.1 million, with 42% of young adults (aged 18–24 years) attending a 2- or 4-year college or university. The National Center for Educational Statistics projects that this trend will continue, with a 13% increase in enrollment of students aged 24 years and younger from 2011 to 2021.4 Colleges are rapidly adopting a range of policies on tobacco, including tobacco-free policies that prohibit tobacco use on the entire grounds for students, faculty, staff, and visitors.Smoke-free college campus policies have been associated with a drop in student smoking rates.5 On North Carolina college campuses, as tobacco policy strength increased (none, designated areas, or tobacco-free), less cigarette butt litter was found on the ground outside building entrances.6 As tobacco control advocates shift focus to promoting comprehensive tobacco-free policies, a more nuanced understanding of the benefits of these policies is necessary.Previous research has indicated that college smoke-free policies lead to a reduction in student smoking rates,5 and strength of policy is linked to cigarette butt litter on college campuses.6 The purpose of this study was to examine the relationship between the strength of the tobacco policy and exposure to secondhand smoke, seeing someone smoking, and intention to smoke on campus. We studied a range of policies on 8 public 4-year colleges and universities in California and found that the stronger the policy provisions, the lower the reported exposure to secondhand smoke, and seeing someone smoking. In addition, students on the tobacco-free campuses reported the lowest intention to smoke on campus in the next 6 months.     

The Effectiveness of Cigarette Price and Smoke-Free Homes on Low-Income Smokers in the United States

Objectives. We examined the effectiveness of state cigarette price and smoke-free homes on smoking behaviors of low-income and high-income populations in the United States.Methods. We used the 2006–2007 Tobacco Use Supplement to the Current Population Survey. The primary outcomes were average daily cigarette consumption and successful quitting. We used multivariable regression to examine the association of cigarette price and smoke-free home policies on these outcomes.Results. High state cigarette price (pack price ≥ $4.50) was associated with lower consumption across all income levels. Although low-income individuals were least likely to adopt smoke-free homes, those who adopted them had consumption levels and successful quit rates that were similar to those among higher-income individuals. In multivariable analysis, both policies were independently associated with lower consumption, but only smoke-free homes were associated with sustained cessation at 90 days.Conclusions. High cigarette prices and especially smoke-free homes have the potential to reduce smoking behaviors among low-income individuals. Interventions are needed to increase adoption of smoke-free homes among low-income populations to increase cessation rates and prevent relapse.High state cigarette prices1–3 and clean indoor air laws4–8 are 2 of the most effective tobacco control policies for decreasing tobacco use5 and increasing cessation on a population level.4–6 These policies have been included in national surveillance surveys of tobacco use.9 Whether these policies are effective among lower-income as well as higher-income smokers is unclear. Some studies, including an econometric analysis,10 have suggested that price and clean air laws have a similar effect in reducing smoking behavior among lower- and higher-income smokers.2,10,11 Others have suggested that such policies may be less effective for lower-income smokers12–14 as they have a higher smoking prevalence,15 higher consumption rate per smoker,16 and lower rates of successful quitting17–19 compared with higher-income smokers. Indeed, the prevalence of smoking among adults living below the federal poverty level (FPL) is almost 50% higher than the prevalence in the general population.15Economic theory suggests that rising cigarette prices should reduce cigarette consumption more in low-income smokers compared with those with higher incomes.2,12,13,20–23 However, studies have shown that low-income smokers vary in their response to rising cigarette prices. Some individuals may compensate for higher prices by relying on lower-priced cigarette products (e.g., generic vs premium brands, discount vs convenience stores, or non–state-taxed products [e.g., from Indian reservations] vs taxed products).23–29 Others who are motivated to quit may react to a price increase as an opportunity to quit smoking or reduce cigarette consumption.3,21 One concern is that the higher prevalence of heavy smoking among low-income smokers may be evidence of impaired personal autonomy such that fewer are able to quit even with a price increase.30 This in combination with the stress of coping with material or environmental constraints may pose significant challenges to smoking cessation.31 Another concern is that high cigarette prices can result in a significant financial burden for low-income smokers.32Social cognitive theory predicts that a person’s motivation to change behavior varies with the social norms of his or her environment.33 Variability in smoking behaviors between low- and high-income smokers may result from different social norms related to smoking.34 The passage of smoke-free policies in communities is one indicator of social norms related to smoking35; a stronger marker is the prevalence of households with smokers who have voluntarily established a smoke-free home.6 Strong clean indoor air laws are associated with increased adoption of smoke-free homes among smokers and nonsmokers.36,37 Smoke-free homes have been associated with reduced exposure to second-hand smoke among nonsmokers, and reduced smoking behaviors among smokers.5,6,38 Lower-income adults are less likely than higher-income adults to adopt smoke-free homes,39,40 reflecting differential smoking norms in the respective communities.To determine whether cigarette prices and smoke-free home policies are effective among smokers of different income levels, we used the 2006–2007 Tobacco Use Supplement to the Current Population Survey (TUS-CPS), a nationally representative cross-sectional survey, to explore the association of these policies with smoking behaviors by income categories indexed on poverty status. The level of excise tax on tobacco products has differed considerably across states.41 Thus, we aggregated self-reported purchase price of cigarettes and compared across states. We examined whether average daily consumption and successful quitting differed by income levels among adults living in states with higher average cigarette prices compared with those with lower prices. We similarly assessed whether an income gradient existed in cigarette consumption and successful quitting among adults living in smoke-free homes relative to non–smoke-free homes. We examined the independent association of state cigarette price and smoke-free homes on smoking behaviors. We hypothesized that smoke-free homes would be a stronger predictor than price in reducing smoking behaviors because smokers may have access to a number of price-minimizing strategies23,26 but lack similar strategies to minimize the effects of smoking restrictions.     

Smoking Policy Change Within Permanent Supportive Housing

Smoke-free policies effectively reduce secondhand smoke (SHS) exposure among non-smokers, and reduce consumption, encourage quit attempts, and minimize relapse to smoking among smokers. Such policies are uncommon in permanent supportive housing (PSH) for formerly homeless individuals. In this study, we collaborated with a PSH provider in San Diego, California to assess a smoke-free policy that restricted indoor smoking. Between August and November 2015, residents completed a pre-policy questionnaire on attitudes toward smoke-free policies and exposure to secondhand smoke, and then 7–9 months after policy implementation residents were re-surveyed. At follow-up, there was a 59.7% reduction in indoor smoking. The proportion of residents who identified as current smokers reduced by 13% (95% CI: ?38, 10.2). The proportion of residents who reported never smelling SHS indoors (apartment 24.2%, 95% CI: 4.2, 44.1; shared areas 17.2%, 95% CI: 1.7, 32.7); in outdoor areas next to the living unit (porches or patio 56.7%, 95% CI: 40.7, 72.8); and in other outdoor areas (parking lot 28.6%, 95% CI: 8.3, 48.9) was lower post-policy compared with pre-policy. Overall, resident support increased by 18.7%; however, the greatest increase in support occurred among current smokers (from 14.8 to 37.5%). Fewer current smokers reported that the policy would enable cessation at post-policy compared to pre-policy. Our findings demonstrate the feasibility of implementing smoke-free policies in PSH for formerly homeless adults. However, policy alone appears insufficient to trigger change in smoking behavior, highlighting the need for additional cessation resources to facilitate quitting.     

Second and Thirdhand Smoke Exposure,Attitudes and Protective Practices: Results from a Survey of Hispanic Residents in Multi-unit Housing

Secondhand and third hand smoke (SHS, THS) exposure is prevalent in multi-unit housing (MUH). Minorities and low-income MUH residents are disproportionally exposed to SHS and THS compared to other populations. This study describes the characteristics, attitudes, knowledge, and behaviors related to SHS, THS and marijuana smoke exposure (MSHS) of a sample of Hispanic tenants in randomly selected MUH units in eastern metro Los Angeles (n?=?402). Although most participants (97%) banned smoking inside their homes, 80% reported infiltration of SHS inside their apartments within the last year. Most (85%) favored a complete ban on smoking in apartment buildings. Twenty-eight percent did not know that marijuana (MSHS) smoke exposure is also harmful to their health. Knowledge scores were higher among Spanish-speakers (p?<?0.05). Given the interpersonal barriers to advocating for change, widespread policy and communication interventions are also necessary to protect Hispanic MUH residents’ rights to clean air in their living space.     

Home Exposure to Secondhand Smoke among People Living in Multiunit Housing and Single Family Housing: a Study of California Adults, 2003–2012

Public health education efforts continue to encourage people to adopt voluntary smoking bans at home; nonetheless, the home remains a place where many people are exposed to secondhand smoke (SHS). Little is known about how SHS exposure in the home differs between adults residing in multiunit housing (MUH) and those residing in single family housing (SFH). This study (1) compared the socio-demographic characteristics, chronic disease conditions, and smoking status of adults living in MUH with those living in SFH, (2) assessed the correlates of living in MUH for adults, and (3) evaluated the association of residency in MUH and SFH with the odds of being exposed to SHS at home using population-based survey data of California adults. Smoking prevalence was significantly higher among MUH residents than SFH residents. The adjusted odds of exposure to SHS at home were 32 % higher for MUH smokers than SFH smokers but were not significantly different for non-smokers. This study presents evidence that there are significant socio-demographic differences between MUH residents and SFH residents and that MUH smokers have higher rates of exposure to SHS at home than SFH smokers after adjusting for other covariates. To reduce home exposure to SHS among MUH residents, it is important to adopt tobacco control policies that are aimed at reducing SHS exposure in and around MUH and at reducing cigarette smoking among current smokers in MUH.     

Depressive Symptomology and Hostile Affect among Latinos Using Housing Rental Assistance: the AHOME Study

Studies show that those residing in households subsidized with federal housing vouchers exhibit fewer mental health problems than residents of public housing. The role of housing conditions and neighborhood quality in this relationship is unclear. This study investigated the relationship between rental assistance, housing and neighborhood conditions, and the risk of depressive symptomology and hostile affect among low-income Latino adults living in the Bronx, NY. Latino adults participating in the Affordable Housing as an Obesity Mediating Environment (AHOME) study were used for analysis. All AHOME participants were eligible for federal low-income housing rental assistance (n = 385) and living in the Bronx, New York (2010–2012). Housing (crowding and structural deficiencies) and neighborhood (physical disorder and social cohesion) were measured by questionnaire during in-home interview. Depressive symptomology was measured using the Center for Epidemiologic Studies Depression Scale Short Form, CES-D 10 (score ≥10). Hostile affect was measured using items from the Cook-Medley Hostility Scale (score ≥ 4). Results suggest residents of Section 8 housing have similar levels of depressive symptomology and hostility compared to residents in public housing or those receiving no federal housing assistance. However, depressive symptomology was significantly associated with maintenance deficiencies [OR = 1.17; CI 1.02, 1.35] and social cohesion [OR = 0.71; CI 0.55, 0.93]. Hostility was significantly associated with perceived crowding [OR = 1.18; CI 1.16, 2.85], neighborhood physical disorder [OR = 1.94; CI 1.12, 3.40], and social cohesion [OR = 0.70; CI 0.50, 0.98]. Low-income housing assistance did not have an independent effect on mental health outcomes. However, characteristics of the housing and neighborhood environments were associated with depressive symptomology and hostility.     

Impact of Mandatory Carbon Monoxide Alarms: An Investigation of the Effects on Detection and Poisoning Rates in New York City

Objectives. We sought to evaluate the impact of New York City’s (NYC’s) 2004 carbon monoxide (CO) alarm legislation on CO incident detection and poisoning rates.Methods. We compared CO poisoning deaths, hospitalizations, exposures reported to Poison Control, and fire department investigations, before and after the law for 2000 to 2010. Use of CO alarms was assessed in the 2009 NYC Community Health Survey.Results. Investigations that found indoor CO levels greater than 9 parts per million increased nearly 7-fold after the law (P < .001). There were nonsignificant decreases in unintentional, nonfire-related CO poisoning hospitalization rates (P = .114) and death rates (P = .216). After we controlled for ambient temperature, the law’s effect on hospitalizations remained nonsignificantly protective (incidence rate ratio = 0.747; 95% confidence interval = 0.520, 1.074). By 2009, 83% of NYC residents reported having CO alarms; only 54% also recently tested or replaced their batteries.Conclusions. Mandating CO alarms significantly increased the detection of potentially hazardous CO levels in NYC homes. Small numbers and detection bias might have limited the discovery of significant decreases in poisoning outcomes. Investigation of individual poisoning circumstances since the law might elucidate remaining gaps in awareness and proper use of CO alarms.Carbon monoxide (CO) is produced by the incomplete combustion of carbon-based fuels, and is a leading cause of environmental poisoning worldwide. In the United States, CO is responsible for more than 2700 deaths annually.1 CO exposure can also cause significant long-term morbidity; an estimated 50% of nonfatal cases develop neurologic sequelae, such as cognitive decline or movement disorders.2,3 Most CO poisoning cases in the United States today are the result of smoke inhalation during fires, but nonfire-related CO poisoning from vehicle emissions, generators, and heating and cooking appliances is also a significant concern. Unintentional nonfire-related CO exposure led to an annual average of 20 636 emergency department visits and 439 deaths from 2004 to 2006.4 Nearly 73% of these exposures occurred in the home, and 13% were work related.Because CO is colorless and odorless, it cannot be detected without the aid of a device. CO alarms are therefore proposed as an important public health measure to limit exposure and reduce CO poisoning.5–7 In New York City (NYC), CO alarms became mandatory in residences, nursing homes, hotels, hospitals, schools, and libraries beginning November 1, 2004 (Local Law 7), except for buildings without and not adjacent to any fossil-fuel burning heating sources or an attached garage.8 The law requires residential building owners to (1) install battery operated or hard-wired alarms with battery back-up within 15 feet of any room lawfully used for sleeping, (2) postapproved notices in common areas indicating the duties of owners and occupants under the law, and (3) provide tenants with information about CO alarms. Tenants, meanwhile, are required to maintain alarms in working order. Schools, hotels, hospitals, and libraries may install a zoned alarm system with central annunciation. A press release issued after signage of the law in May 2004 notified the public of the new regulations.9 NYC’s CO alarm law preceded Amanda’s Law, which applied the same provisions to residential buildings throughout New York State, effective February 22, 2010.10The NYC Health Code was simultaneously updated in November 2004 to require health care providers to immediately report CO poisoning to the NYC Poison Control Center (NYCPCC), so that emergency personnel could be rapidly deployed to sites of exposure in the event other tenants were still at risk. In 2005, an estimated 65% of NYC residents lived in renter-occupied housing units.11We assessed the potential impact of Local Law 7 on the incidence of unintentional CO poisoning and deaths using data from the NYC Office of Vital Records and New York State hospital discharge data. We also sought to determine the law’s effect on CO incident detection as measured by the number of Fire Department of New York City (FDNY) investigations for CO, and the potential impact of the related Health Code update on the frequency of health care provider reporting to the NYCPCC. Our final objective was to assess how many residents reported having CO alarms installed and maintained 5 years after the law took effect.