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Vijayaraghavan M, Hartman-Filson M, Vyas P, Katyal T, Nguyen T, Handley MA. Multi-Level Influences of Smoke-Free Policies in Subsidized Housing: Applying the COM-B Model and Neighborhood Assessments to Inform Smoke-Free Policies. Health Promot Pract 2023:15248399231174925. [PMID: 37209138 DOI: 10.1177/15248399231174925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Smoke-free policies in multi-unit housing are associated with reduced exposure to secondhand smoke (SHS); however, attitudes toward comprehensive smoke-free policies among residents in subsidized multi-unit housing are unknown. In this mixed-methods study, we explored the socio-ecological context for tobacco and cannabis use and attitudes toward policies restricting indoor use of these products through interviews with residents (N = 134) and staff (N = 22) in 15 federally subsidized multi-unit housing in San Francisco, California. We conducted a geo-spatial and ethnographic environmental assessment by mapping alcohol, cannabis, and tobacco retail density using ArcGIS, and conducted systematic social observations of the neighborhood around each site for environmental cues to tobacco use. We used the Capability, Opportunity, and Motivation behavior (COM-B) model to identify factors that might influence implementation of smoke-free policies in multi-unit housing. Knowledge and attitudes toward tobacco and cannabis use, social norms around smoking, neighborhood violence, and cannabis legalization were some of the social-ecological factors that influenced tobacco use. There was spatial variation in the availability of alcohol, cannabis, and tobacco stores around sites, which may have influenced residents' ability to maintain smoke-free homes. Lack of skill on how to moderate indoor smoking (psychological capability), lack of safe neighborhoods (physical opportunity), and the stigma of smoking outdoors in multi-unit housing (motivation) were some of the barriers to adopting a smoke-free home. Interventions to increase adoption of smoke-free policies in multi-unit housing need to address the co-use of tobacco and cannabis and commercial and environmental determinants of tobacco use to facilitate smoke-free living.
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Affiliation(s)
| | | | - Priyanka Vyas
- California State University, East Bay, Hayward, CA, USA
| | - Toshali Katyal
- University of California, San Francisco, San Francisco, CA, USA
| | - Tram Nguyen
- University of California, San Francisco, San Francisco, CA, USA
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Titus AR, Mijanovich TN, Terlizzi K, Ellen IG, Anastasiou E, Shelley D, Wyka K, Elbel B, Thorpe LE. 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. Am J Epidemiol 2023; 192:25-33. [PMID: 35551590 PMCID: PMC10175658 DOI: 10.1093/aje/kwac089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 01/11/2023] Open
Abstract
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.
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Odes R, Alway J, Kushel M, Max W, Vijayaraghavan M. The smoke-free home study: study protocol for a cluster randomized controlled trial of a smoke-free home intervention in permanent supportive housing. BMC Public Health 2022; 22:2076. [PMCID: PMC9664594 DOI: 10.1186/s12889-022-14423-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/23/2022] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
Formerly chronically homeless adults who live in permanent supportive housing (PSH) have high prevalence of smoking. It is uncommon to find smoke-free policies in PSH because of the concern that such policies contradict PSH’s harm reduction framework and could increase homelessness should residents lose their housing because of the policy. However, in the absence of such policies, non-smoking PSH residents face the harmful effects of secondhand smoke exposure while residents who smoke see increased risks from high rates of smoking throughout their residence. Our pilot work highlighted the feasibility and acceptability of an intervention designed to promote voluntary adoption of a smoke-free home. Here we report a protocol for a cluster randomized controlled trial of the smoke-free home intervention for formerly chronically homeless residents in PSH.
Methods
The smoke-free home intervention provides face-to-face counseling and instruction to PSH residents on how to adopt a smoke-free home and offers training for PSH staff on how to refer residents to tobacco cessation services. We will randomize 20 PSH sites in the San Francisco Bay Area to either the intervention or wait-list control arms. We will enroll 400 PSH residents who smoke cigarettes in their housing unit and 120 PSH staff who work at the sites. At baseline, three- and six-months follow-up, we will ask residents to report their tobacco use and cessation behaviors and adoption of smoke-free homes. We will ask staff to answer questions on their knowledge, attitudes, practices, and barriers related to supporting residents’ smoking cessation. The primary outcome for PSH residents is adoption of smoke-free homes for 90 days or more at six-months follow-up, and the secondary outcome is point prevalence tobacco abstinence. The primary outcome for PSH staff is change in Smoking Knowledge Attitudes Practices survey score.
Discussion
Voluntary adoption of smoke-free homes is a promising approach for reducing exposure to secondhand smoke and reducing tobacco use among a population facing high rates of tobacco-related disease, and is aligned with PSH’s harm reduction framework. Findings from this study have the potential to inform adoption of tobacco control policies among vulnerable populations most at risk for smoking-related harms.
Trial registration
This study was registered with the U.S. National Institute of Health Clinical Trials register on April 22, 2021: NCT04855357.
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Childs E, Geller AC, Brooks DR, Davine J, Kane J, Keske R, Anthony J, Rees VW. Assessing Smoke-Free Housing Implementation Approaches to Inform Best Practices: A National Survey of Early-Adopting Public Housing Authorities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073854. [PMID: 35409538 PMCID: PMC8997519 DOI: 10.3390/ijerph19073854] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/26/2022]
Abstract
Secondhand smoke (SHS) exposure causes chronic illness and occurs at a higher prevalence in low-income communities than the general public. In 2018, the U.S. Department of Housing and Urban Development (HUD) instituted a smoke-free housing rule for Public Housing Authorities (PHAs) to address persistent health inequities. However, the success of smoke-free housing requires evidence to inform effective implementation approaches. A mixed-methods, cross-sectional survey was conducted in a national sample of PHAs. Questions focused on housing officials’ use of specific implementation strategies. Adjusted odds ratios were used to assess associations between implementation approaches and variations among PHAs (i.e., region, size, or recency of policy adoption). Qualitative analyses were conducted to assess the perceived effectiveness of implementation strategies. Resident engagement, staff training, and smoking cessation support were the most frequently used implementation strategies. Engagement with local stakeholders was cited less frequently. Enforcement actions were limited with no violations referred to housing court. Support for policy adherence was identified as a sixth implementation strategy. While most PHAs used at least some evidence-informed implementation strategies, a lack of a systematic approach may limit overall effectiveness. Further research is required to resolve implementation barriers experienced disproportionately by a subset of PHAs, and to inform a best practice implementation framework that meets the needs of a heterogeneous population.
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Affiliation(s)
- Ellen Childs
- Division of Health and Environment, Abt Associates, Rockville, MD 20852, USA;
| | - Alan C. Geller
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (A.C.G.); (J.D.)
| | - Daniel R. Brooks
- Department of Epidemiology, Boston University School of Public Health, Boston, MA 02118, USA;
| | - Jessica Davine
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (A.C.G.); (J.D.)
| | - John Kane
- Boston Housing Authority, Boston, MA 02111, USA;
| | - Robyn Keske
- Football Players Health Study, Harvard Medical School, Boston, MA 02215, USA;
| | | | - Vaughan W. Rees
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (A.C.G.); (J.D.)
- Correspondence: ; Tel.: +1-617-432-6345
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Cardozo RA, Feinberg A, Tovar A, Vilcassim MJR, Shelley D, Elbel B, Kaplan S, Wyka K, Rule AM, Gordon T, Thorpe LE. A protocol for measuring the impact of a smoke-free housing policy on indoor tobacco smoke exposure. BMC Public Health 2019; 19:666. [PMID: 31146711 PMCID: PMC6543633 DOI: 10.1186/s12889-019-7043-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/23/2019] [Indexed: 01/30/2023] Open
Abstract
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.
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Affiliation(s)
- Rodrigo Arce Cardozo
- Department of Population Health, New York University School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Alexis Feinberg
- Department of Population Health, New York University School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Albert Tovar
- Department of Population Health, New York University School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - M. J. Ruzmyn Vilcassim
- Department of Environmental Medicine, New York University School of Medicine, 341 East 25th Street, New York, NY 10010 USA
| | - Donna Shelley
- Department of Population Health, New York University School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Brian Elbel
- Department of Population Health, New York University School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Sue Kaplan
- Department of Population Health, New York University School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Katarzyna Wyka
- Graduate School of Public Health and Health Policy, City University of New York, New York, NY 10027 USA
| | - Ana M. Rule
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe Street, Baltimore, MD 21205 USA
| | - Terry Gordon
- Department of Environmental Medicine, New York University School of Medicine, 341 East 25th Street, New York, NY 10010 USA
| | - Lorna E. Thorpe
- Department of Population Health, New York University School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
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Jiang N, Thorpe L, Kaplan S, Shelley D. Perceptions about the Federally Mandated Smoke-Free Housing Policy among Residents Living in Public Housing in New York City. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15102062. [PMID: 30241291 PMCID: PMC6210957 DOI: 10.3390/ijerph15102062] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 11/20/2022]
Abstract
Background: To assess residents’ attitudes towards the United States (U.S.) Department of Housing and Urban Development’s new smoke-free public housing policy, perceptions about barriers to policy implementation, and suggestions for optimizing implementation. Methods: In 2017, we conducted 10 focus groups among 91 residents (smokers and nonsmokers) living in New York City public housing. Results: Smokers and nonsmokers expressed skepticism about the public housing authority’s capacity to enforce the policy due to widespread violations of the current smoke-free policy in common areas and pervasive use of marijuana in buildings. Most believed that resident engagement in the roll-out and providing smoking cessation services was important for compliance. Resident expressed concerns about evictions and worried that other building priorities (i.e., repairs, drug use) would be ignored with the focus now on smoke-free housing. Conclusions: Resident-endorsed strategies to optimize implementation effectiveness include improving the access to cessation services, ongoing resident engagement, education and communication to address misconceptions and concerns about enforcement, and placing smoke-free homes in a larger public housing authority healthy housing agenda.
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Affiliation(s)
- Nan Jiang
- Department of Population Health, School of Medicine, New York University, New York, NY 10016, USA.
| | - Lorna Thorpe
- Department of Population Health, School of Medicine, New York University, New York, NY 10016, USA.
| | - Sue Kaplan
- Department of Population Health, School of Medicine, New York University, New York, NY 10016, USA.
| | - Donna Shelley
- Department of Population Health, School of Medicine, New York University, New York, NY 10016, USA.
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