Individual, social, and environmental factors associated with support for smoke-free housing policies among subsidized multiunit housing tenants

Contamination of surfaces in children's homes with nicotine and the potent carcinogenic tobacco-specific nitrosamine NNK

BACKGROUND

Tobacco smoke exposure (TSE) through secondhand and thirdhand smoke is a modifiable risk factor that contributes to childhood morbidity. Limited research has assessed surface TSE pollution in children's environments as a potential source of thirdhand smoke exposure, and none have examined levels of the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) on surfaces.

OBJECTIVE

This study measured surface NNK and nicotine in children's homes and associations with sociodemographics and parent-reported TSE behaviors. We assessed correlations of surface NNK and nicotine with dust NNK, dust nicotine, and child cotinine.

METHODS

Home surface wipe NNK and nicotine data from 84 children who lived with smokers were analyzed. Tobit and simple linear regression analyses were conducted to assess associations of surface NNK and nicotine with child characteristics. Spearman's (ρ) correlations assessed the strength of associations between environmental markers and child cotinine.

RESULTS

Nearly half (48.8%) of children's home surfaces had detectable NNK and 100% had detectable nicotine. The respective geometric means (GMs) of surface NNK and nicotine loadings were 14.0 ng/m2 and 16.4 µg/m2. Surface NNK positively correlated with surface nicotine (ρ = 0.54, p < 0.001) and dust NNK (ρ = 0.30, p = 0.020). Surface nicotine positively correlated with dust NNK (ρ = 0.42, p < 0.001) and dust nicotine (ρ = 0.24, p = 0.041). Children with household incomes ≤$15,000 had higher surface NNK levels (GM = 18.7 ng/m2, p = 0.017) compared to children with household incomes >$15,000 (GM = 7.1 ng/m2). Children with no home smoking bans had higher surface NNK (GM = 18.1 ng/m2, p = 0.020) and surface nicotine (GM = 17.7 µg/m2, p = 0.019) levels compared to children with smoking bans (GM = 7.5 ng/m2, 4.8 µg/m2, respectively).

IMPACT

Although nicotine on surfaces is an established marker of thirdhand smoke pollution, other thirdhand smoke contaminants have not been measured on surfaces in the homes of children living with smokers. We provide evidence that the potent carcinogenic tobacco-specific nitrosamine NNK was detectable on surfaces in nearly half of children's homes, and nicotine was detectable on all surfaces. Surface NNK was positively correlated with surface nicotine and dust NNK. Detectable surface NNK levels were found in homes with indoor smoking bans, indicating the role of NNK as a persistent thirdhand smoke pollutant accumulating on surfaces as well as in dust.

Resident Support for the Federally Mandated Smoke-Free Rule in Public Housing: 2018-2022

This study examines support for the Department of Housing and Urban Development's (HUD) mandatory smoke-free rule up to four years post-rule among smokers and non-smokers. A repeated cross-sectional design was used where District of Columbia public housing residents aged 18+ (n = 529) completed surveys during three time points: July 2018 (pre-rule), November 2018-March 2020 (post-rule), and September 2020-December 2022 (post-rule + COVID-19). Full support for the rule was indicated by agreeing that smoking should not be allowed in all indoor locations and within 25 feet of buildings. Descriptive statistics showed significant differences in support across time for smokers (5.3%, 30.7%, and 22.5%, respectively) and similar support across time for nonsmokers (48.2%, 52.2%, and 40.0%, respectively). In unstratified regression analysis, pre-rule support was lower than when the rule was in effect (aOR = 0.47, 95% CI = 0.25, 0.90), and tobacco users were less likely to support the rule (aOR = 0.34, 95% CI = 0.23, 0.50). Stratified logistic regression results showed that pre-rule support was lower among smokers compared to post-rule support (aOR = 0.14, 95% CI = 0.03, 0.59); support among nonsmokers did not vary by time. Findings overall indicate low support for the smoke-free rule up to 4 years post-implementation. Engaging residents with the rule and promoting health and well-being may further enhance policy effectiveness and acceptance.

A randomized control trial to support smoke-free policy compliance in public housing

BACKGROUND

Smoke-free housing policies in multiunit housing are increasingly widespread interventions to reduce smoking and secondhand smoke exposure. Little research has identified factors that impede compliance with smoke-free housing policies in low-income multiunit housing and test corresponding solutions.

METHODS

We are using an experimental design to test two compliance support interventions: (A) a "compliance through reduction (via relocation and reduction in personal smoking) and cessation" intervention targets households with smokers and involves support to shift smoking practices to areas beyond the apartment or building setting, reduce personal smoking, and deliver in-residence smoking cessation support services via trained peer educators and (B) a "compliance through resident endorsement" intervention involving voluntary adoption of smoke-free living environments through personal pledges, visible door markers, and/or via social media. We will compare randomly sampled participants in buildings that receive A or B or A plus B to the NYCHA standard approach.

DISCUSSION

This RCT addresses key gaps in knowledge and capitalizes on key scientific opportunities by (1) leveraging the federal mandate to ban smoking in a public housing system of more than sufficient size to conduct an adequately powered RCT; (2) expanding our understanding of smoke-free policy compliance beyond policy implementation by testing two novel treatments: (a) in-residence smoking cessation and (b) resident endorsement, while (3) addressing population and location-specific tobacco-related disparities. At the conclusion of the study, this RCT will have leveraged a monumental policy shift affecting nearly half a million NYC public housing residents, many of whom disproportionately experience chronic illness and are more likely to smoke and be exposed to secondhand smoke than other city residents. This first-ever RCT will test the effects of much-needed compliance strategies on resident smoking behavior and secondhand smoke exposure in multiunit housing.

TRIAL REGISTRATION

Clinical Trials Registered, NCT05016505. Registered on August 23, 2021.

Policy-relevant differences between secondhand and thirdhand smoke: strengthening protections from involuntary exposure to tobacco smoke pollutants

Starting in the 1970s, individuals, businesses and the public have increasingly benefited from policies prohibiting smoking indoors, saving thousands of lives and billions of dollars in healthcare expenditures. Smokefree policies to protect against secondhand smoke exposure, however, do not fully protect the public from the persistent and toxic chemical residues from tobacco smoke (also known as thirdhand smoke) that linger in indoor environments for years after smoking stops. Nor do these policies address the economic costs that individuals, businesses and the public bear in their attempts to remediate this toxic residue. We discuss policy-relevant differences between secondhand smoke and thirdhand smoke exposure: persistent pollutant reservoirs, pollutant transport, routes of exposure, the time gap between initial cause and effect, and remediation and disposal. We examine four policy considerations to better protect the public from involuntary exposure to tobacco smoke pollutants from all sources. We call for (a) redefining smokefree as free of tobacco smoke pollutants from secondhand and thirdhand smoke; (b) eliminating exemptions to comprehensive smoking bans; (c) identifying indoor environments with significant thirdhand smoke reservoirs; and (d) remediating thirdhand smoke. We use the case of California as an example of how secondhand smoke-protective laws may be strengthened to encompass thirdhand smoke protections. The health risks and economic costs of thirdhand smoke require that smokefree policies, environmental protections, real estate and rental disclosure policies, tenant protections, and consumer protection laws be strengthened to ensure that the public is fully protected from and informed about the risks of thirdhand smoke exposure.

Public Housing Resident Perspectives on Smoking, Barriers for Smoking Cessation, and Changes in Smoking Mandates

Background

Individuals from low-income groups report disproportionate rates of cigarette use, secondhand smoke (SHS) exposure with increased morbidity and mortality. Smoking bans in public housing have been enacted in attempt to reduce tobacco use and SHS exposure among lower income individuals. This study investigated the support needs of tobacco users living in two public housing complexes in Detroit, Michigan (USA), including their perspectives on smoking, resources and barriers for smoking cessation, and the impact of policy changes.

Methods

This is a mixed-methods study, using a qualitative focus groups approach and a short survey, public housing residents interview data was analyzed to explore themes related to smoking-related issues. Specifically, six themes were assessed across four focus groups: (1) Quitting Smoking, (2) Current Smoking Cessation Resources, (3) Legal Mandates, (4) Education and Perceptions of Smoking, (5) Community Needs and Barriers, and (6) Medical Experiences.

Results

There were 59 participants; the majority (39/42, 93%) of smokers reported at least one quit attempt. During the focus groups, several participants indicated a desire to quit smoking but reported barriers to smoking cessation, such as lack of access to medications, social triggers to continue smoking, and socioeconomic stressors. A number of suggestions were provided to improve smoking cessation resources, including support groups, graphic images of smoking-related diseased tissue, and better communication with health care providers.

Conclusions

These findings demonstrate smoking bans in two public housing complexes can be effective yet are dependent upon a complex set of issues, including numerous barriers to care.

A Qualitative Study of Unfairness and Distrust in Smoke-free Housing

Objectives: Whereas smoke-free housing (SFH) has the potential to protect residents from tobacco smoke, evidence suggests that SFH could lead to increased indoor smoking. In this study, we examine how perceptions of a residential smoking ban could be related to non-compliance. Methods: We conducted 8 focus group interviews of low-income housing residents living in Norfolk, Virginia (N=53). Interviews were semi-structured and based on a list of guided questions related to SFH compliance, developed in partnership with a standing community advisory board comprised of low-income housing residents. Results: Several themes emerged, including pervasive non-compliance, perceived unfairness and shame, barriers to compliance, and distrust of the housing authority. Smokers reported behavior primarily motivated by punishment avoidance, rather than out of any perceived obligation to comply with the ban. Conclusions: Results led us to consider Procedural Justice Theory as a conceptual framework, in which compliance is directly related to perceptions about the legitimacy of a rule or authority. When compliance is low due to a lack of perceived legitimacy, SFH should be adapted to promote changes in smoking behavior. We offer specific theory-supported adaptations to SFH focused on trust-building and improving perceived fairness.

Proposal for smoke-free public housing: a systematic review of attitudes and preferences from residents of multi-unit housing

A policy proposal to ban public housing smoking indoors has received support, but it is unclear how certain affected groups, specifically smokers in housing units, perceive such a policy. To review the literature on attitudes and perceptions of housing unit tenants towards an indoor smoke-free housing policy, using various databases, we searched articles for attitudes towards smoking ban enforcement in housing units. We identified fourteen articles. Non-smokers heavily favored indoor policies and current smokers heavily opposed them. Current smokers represented a substantial minority in the reviewed articles, resulting in overall outcomes of the surveys driven by non-smokers. Studies investigating attitudes about housing smoking bans largely represent the views of non-smokers and lack data about barriers and concerns of tenants who do not support a smoke-free policy. Future studies should investigate if such a discrepancy impacts the efficacy of smoke-free housing policies.

Uneven Access to Smoke-Free Laws and Policies and Its Effect on Health Equity in the United States: 2000-2019

Tobacco control measures have played an important role in the reduction of the cigarette smoking prevalence among US adults.However, although overall smoking prevalence has declined, it remains high among many subpopulations that are disproportionately burdened by tobacco use, resulting in tobacco-related health disparities. Slow diffusion of smoke-free laws to rural regions, particularly in the South and Southeast, and uneven adoption of voluntary policies in single-family homes and multiunit housing are key policy variables associated with the disproportionate burden of tobacco-related health disparities in these subpopulations.Developing policies that expand the reach of comprehensive smoke-free laws not only will facilitate the decline in smoking prevalence among subpopulations disproportionately burdened by tobacco use but will also decrease exposure to secondhand smoke and further reduce tobacco-caused health disparities in the United States.

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.

Smoke-free environment policy in Vietnam: what did people see and how did they react when they visited various public places?

Introduction

Since Vietnam has signed WHO framework on tobacco control (FCTC) in 2003 and has issued tobacco control law in 2013, there has been little research concerning about what impacts smoke-free regulations have had on public compliance. The objective of this study was to assess public exposure to secondhand smoke and reaction toward smoke-free policy regulations in Vietnam and the associated factor.

Methods

Using the design of GATS (Global Adult Tobacco Survey), a nationally representative sample of 8,996 adults were approached for data collection. Logistic regression was used to examine the associated factor.

Results

The study revealed that the prevalence of respondents exposed to secondhand smoke was much higher in bars/café/tea shops (90.07%) and restaurants (81.81%) than in any other public places, universities (36.70%), government buildings (31.12%), public transport (20.04%), healthcare facilities (17.85%) and schools (15.84%). 13.23% of respondents saw smokers violate smoke-free regulations. Among those who saw them violate smoke-free regulations, just one-third cautioned them to stop smoking. Strikingly, a higher rate of cautioning smokers to stop smoking was observed among the older, married, and better educated respondents. Respondents who were married, better educated and in lower economic status were more likely to remind smokers to stop smoking.

Conclusions

The study has called for strengthening two of the six MPOWER (Monitor, Protect, Offer, Warn, Enforce and Raise) components of the tobacco free initiative introduced by WHO, Monitoring tobacco use and prevention policies and Protecting people from tobacco smoke.

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.

Qualitative Assessment of Smoke-Free Policy Implementation in Low-Income Housing: Enhancing Resident Compliance

PURPOSE

As public housing agencies and other low-income housing providers adopt smoke-free policies, data are needed to inform implementation approaches that support compliance.

DESIGN

Focused ethnography used including qualitative interviews with staff, focus groups with residents, and property observations.

SETTING

Four low-income housing properties in Massachusetts, 12 months postpolicy adoption.

PARTICIPANTS

Individual interviews (n = 17) with property staff (managers, resident service coordinators, maintenance, security, and administrators) and focus groups with resident smokers (n = 28) and nonsmokers (n = 47).

MEASURES

Informed by the social-ecological model: intrapersonal, interpersonal, organizational, and community factors relating to compliance were assessed.

ANALYSIS

Utilized MAXQDA in a theory-driven immersion/crystallization analytic process with cycles of raw data examination and pattern identification until no new themes emerged.

RESULTS

Self-reported secondhand smoke exposure (SHSe) was reduced but not eliminated. Challenges included relying on ambivalent maintenance staff and residents to report violations, staff serving as both enforcers and smoking cessation counsellors, and inability to enforce on nights and weekends. Erroneous knowledge of the policy, perception that SHSe is not harmful to neighbors, as well as believing that smokers were losing their autonomy and being unfairly singled out when other resident violations were being unaddressed, hindered policy acceptance among resident smokers. The greatest challenge to compliance was the lack of allowable outdoor smoking areas that may have reduced the burden of the policy on smokers.

CONCLUSION

Smoke-free policy implementation to support compliance could be enhanced with information about SHSe for smokers and nonsmokers, cessation support from external community partners, discussion forums for maintenance staff, resident inclusion in decision-making, and framing the policy as part of a broader wellness initiative.

Perceptions about the Federally Mandated Smoke-Free Housing Policy among Residents Living in Public Housing in New York City

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.

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.

Attitudes and experiences with secondhand smoke and smoke-free policies among subsidised and market-rate multiunit housing residents living in six diverse communities in the USA

BACKGROUND

Given that higher smoking rates persist among lower socioeconomic populations, multiunit housing (MUH) environments may result in higher secondhand smoke (SHS) exposures among subsidised MUH residents. This cross-sectional assessment compares experiences with SHS and smoke-free policies among subsidised and market-rate MUH residents living in six US communities.

METHODS

MUH residents (n=1565) were surveyed regarding their smoke-free rules (home and building), SHS exposures and preferences towards smoke-free policies. Binary logistic regression identified predictors of each outcome, focusing on differences by subsidised housing status (subsidised vs market rate).

RESULTS

Among residents enforcing smoke-free home rules (76%, overall), 50% reported SHS incursions into their unit. Only 23% reported living in a smoke-free building; 56% of those living in smoking-allowable buildings reported preferences towards smoke-free building policies. Among market-rate housing residents, smoke-free home (OR=4.18) and building (OR=2.26) rules were significantly higher when children were present. Smoke-free building rules reduced the odds of SHS incursions among market-rate housing residents (OR=0.50), but no association was observed among subsidised housing residents. Non-smoking subsidised housing residents exhibited stronger preferences for smoke-free policies compared with those in market-rate housing.

DISCUSSION

Smoke-free home rules may not protect MUH residents from SHS exposures, particularly in subsidised MUH. Although strong preferences towards smoke-free policies were present overall, subsidised MUH residents may have fewer alternative smoke-free housing options available. Therefore, all publicly funded housing should be smoke free to protect these vulnerable populations. However, continued efforts to encourage privately owned MUH operators to adopt smoke-free policies are also necessary.

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.

Attitudes towards Potential New Tobacco Control Regulations among U.S. Adults

Favorable attitudes towards tobacco control policies can facilitate their implementation and success. We examined attitudes toward four potential U.S. Federal tobacco regulations (banning menthol from cigarettes, reducing nicotine levels in cigarettes, banning candy and fruit flavored electronic cigarettes, and banning candy and fruit flavored little cigars and cigarillos) and associations with individual and state variables. A nationally representative phone survey of 4337 adults assessed attitudes toward potential policies. Weighted logistic regression was used to assess relationships between attitudes and demographic factors, smoking behavior, beliefs about the government (knowledge, trust, and credibility), exposure to tobacco control campaigns, and state variables from the US Centers for Disease Control and Prevention (CDC) State Tobacco Activities Tracking and Evaluation (STATE) System. Most respondents supported three out of four policies. Respondents that were female, non-white, Latino, living below the poverty line, had less than high school education, were of older age, did not smoke, had higher trust in government, and were exposed to national tobacco control campaigns had higher odds of expressing favorable attitudes toward potential new tobacco regulations than did their counterparts. No state-level effects were found. While differences in attitudes were observed by individual demographic characteristics, behaviors, and beliefs, a majority of participants supported most of the potential new tobacco regulations surveyed.

Relation between individual factors and support for smoking bans in bars in Greece: A cross-sectional study of the 2013 Global Adult Tobacco Survey (GATS)

INTRODUCTION

Smoking rates among the general population and among youth are decreasing in Greece. Low compliance with smoke-free legislation in indoor places in Greece renders non-smokers exposed to secondhand smoke, especially when frequenting bars. The aim of the current study was to identify the factors related to support for smoking bans in bars in Greece.

METHODS

A cross-sectional secondary data analysis was conducted on the 2013 Greek Global Adult Tobacco Survey. Multivariate regression was used to analyze individual factors and their relation to support for the smoking ban in bars. The total sample was nationally representative of the Greek population and included 3961 residents over the age of 15 with 2061 supporting a ban in bars.

RESULTS

Overall, 50.5% (95% CI: 46.5-54.4) of Greeks supported the smoking ban in bars. Among them, 1,832 (74.9%, 95% CI=70.1-79.1) were non-smokers and 229 (13.7%, 95% CI=10.6-17.5) were smokers. Age over 65 years was significantly related to increased support for the smoking ban in bars compared to those aged 15-24 years (p<0.05). Belief that secondhand smoke causes lung cancer was significantly related (p<0.001) to having increased support for the ban. Increased knowledge of smoking-related harm was significantly related to increased support for the ban in bars (p<0.001). Male non-smokers were significantly less likely to support the ban in bars than females (p<0.05).

CONCLUSIONS

Increasing knowledge and awareness of smoking-related harm will enhance smoking ban support and compliance, improving tobacco prevention and cessation, especially among the youth and young adults.

Cigarette smoking and adverse health outcomes among adults receiving federal housing assistance

Cigarette smoking is higher among low-income adults and individuals who reside in federally assisted housing are particularly susceptible to the adverse effects of smoking and secondhand smoke exposure. This study assessed smoking-related behaviors and health outcomes among U.S. adults who received federal housing assistance during 2006-2012. National Health Interview Survey data linked with administrative data from the U.S. Department of Housing and Urban Development were analyzed; 5218 HUD-assisted adults were assessed. Demographic characteristics associated with smoking, including frequency and consumption, were assessed among adult cigarette smokers. Fourteen adverse health outcomes were examined among cigarette smoking and nonsmoking adults. One-third (33.6%) of HUD-assisted adults were current cigarette smokers. Smoking prevalence was highest among adults aged 25-44 (42.5%), non-Hispanic whites (39.5%), and adults who resided in households with children (37.5%). Half attempted to quit in the past year; 82.1% were daily smokers; and, 35.8% of daily smokers reported smoking 20+ cigarettes a day. Multivariable analyses revealed that compared to nonsmokers, cigarette smokers had increased likelihood of reporting fair or poor health (95% CI: 1.04-1.52), chronic obstructive pulmonary disease (CI: 1.87-3.06), disability (CI: 1.25-1.83), asthma (CI: 1.02-1.55), serious psychological distress (CI: 1.39-2.52), >1 emergency room visit in the past year (CI: 1.09-1.56), and ≥10 work loss days in the past year (CI: 1.15-3.06). Adults who receive housing assistance represent an at-risk population for adverse health outcomes associated with smoking and secondhand smoke. Housing assistance programs provide a valuable platform for the implementation of evidence-based tobacco prevention and control measures, including smokefree policies.

Tobacco Control and Treatment for the Pediatric Clinician: Practice, Policy, and Research Updates

Tobacco use is the leading cause of preventable death in the United States, and exposure to tobacco smoke harms children from conception forward. There is no safe level of tobacco exposure. Although overall smoking rates have declined, the advent of new products, such as electronic cigarettes, threatens to perpetuate nicotine addiction without clear health benefits. In addition to reviewing traditional and new tobacco products, we discuss the unique role that pediatricians should play in tobacco treatment and control efforts. New policies and technologies can empower pediatric clinicians and pediatric health care systems to help parent smokers quit, and new policies outside of the health care setting might help prevent smoking initiation as well as improve cessation treatments. Future research is needed to continue to study the consequences of tobacco use exposure as well as the best ways to help patients and parents stop tobacco use.

Smoking and attitudes toward smoking policy at a University in Egypt

To assess smoking behavior, knowledge of smoking harm, and attitudes toward campus smoking policy at an Egyptian university, an online survey of students, staff, and faculty was conducted (N = 992). The smoking prevalence of 38% among men was in line with Egypt's national average, but the smoking prevalence among women of 20% was much higher than the national average. Smoking status influenced beliefs about smoking harm and attitudes toward smoking policy, with nonsmokers having stronger beliefs about the harm of smoking and showing stronger support for smoking regulations than smokers. Smokers were more knowledgeable about smoking policy than were nonsmokers and differed slightly in their preferences for smoking policy enforcement strategies. These findings contribute to our understanding of how to tailor college smoking policy and programs to an Egyptian context.

Support for smoke-free multi-unit housing policies among racially and ethnically diverse, low-income seniors in South Florida

Previous studies have gauged support for implementing smoke-free multi-unit housing (MUH) policies in the United States, but none have specifically examined attitudes among racially and ethnically diverse elders living in low-income MUH. We surveyed a convenience sample of elders 62 years of age and older (n = 807) across 24 low-income housing properties in Broward County, Florida in order to assess residents' smoking behaviors, exposure to second-hand smoke, and support for smoke-free policies. The study sample was ethnically and racially diverse with Hispanics comprising more than 61 % of the population, and 22 % identifying as Black or other races. Although close to 22 % of the sample were former smokers, only 9 % of residents reported being current smokers. The majority of residents surveyed supported no-smoking policies: 75 % support no-smoking policies for individual units; 77 % supported no-smoking policies in common areas; and, 68 % supported no-smoking policies in outdoor areas. Over 29 % of residents surveyed reported being exposed to secondhand smoke entering their units from elsewhere in their building. Residents who reported having a home smoking rule were more than twice as likely to support an indoor policy compared to residents who allowed smoking anywhere in their home (OR = 2.36; 95%CI 1.25-4.43; p ≤ 0.01), and nonsmoking residents were nearly three times as likely to support an indoor policy compared to smokers (OR = 2.89; 95%CI 1.44-5.79; p ≤ 0.01). Support for an indoor policy was not modified by age, gender, ethnicity or race. . This study demonstrates that elders living in low-income MUH properties overwhelmingly supported the implementation of smoke-free policies.

Smoke-free multiunit housing: a review of the scientific literature

OBJECTIVE

Multiunit housing (MUH) residents are susceptible to secondhand smoke (SHS) exposure, which can transfer between living units. This review summarises existing scientific literature relevant to smoke-free MUH, discusses knowledge gaps and provides recommendations for future research to inform public health action.

DATA SOURCES

We conducted a systematic search of peer-reviewed articles using three databases: EBSCOhost CINAHL, PubMed and Web of Science.

STUDY SELECTION

Article titles, abstracts and text were reviewed to ascertain three inclusion criteria: (1) English language; (2) conducted in the USA; (3) reported on baseline data, development, implementation or evaluation of smoke-free MUH.

DATA EXTRACTION

We used a multistep process to identify eligible articles: (1) two reviewers separately evaluated article titles; (2) two reviewers separately evaluated abstracts and (3) one reviewer read each article and determined inclusion eligibility.

DATA SYNTHESIS

We identified and included 35 articles published during 2001-2014, grouped based on broad themes: MUH resident (n=16); MUH operator (n=6); environmental monitoring and biomarkers (n=9); economic (n=2); legal (n=3); and implementation process and policy impact (n=8). Studies with multiple themes were included in all relevant groups.

CONCLUSIONS

Existing literature has focused on self-reported, cross-sectional studies of MUH residents and operators; some studies of environmental markers, biomarkers and economic indicators have also been conducted. Future research on smoke-free MUH policy compliance and enforcement, and on the impact of these policies on smoking behaviours and health outcomes, could further inform public health planning, policy and practice. Despite these gaps, the current literature provides sufficient evidence for action to eliminate SHS exposure in MUH.

Support for indoor bans on electronic cigarettes among current and former smokers

OBJECTIVES

Electronic cigarette (e-cigarette) use is increasing in the U.S. Although marketed as a safer alternative for cigarettes, initial evidence suggests that e-cigarettes may pose a secondhand exposure risk. The current study explored the prevalence and correlates of support for e-cigarette bans.

METHODS

A sample of 265 current/former smokers completed a cross-sectional telephone survey from June-September 2014; 45% Black, 31% White, 21% Hispanic. Items assessed support for home and workplace bans for cigarettes and e-cigarettes and associated risk perceptions.

RESULTS

Most participants were aware of e-cigarettes (99%). RESULTS demonstrated less support for complete e-cigarette bans in homes and workplaces compared to cigarettes. Support for complete e-cigarette bans was strongest among older, higher income, married respondents, and former smokers. Complete e-cigarette bans were most strongly endorsed when perceptions of addictiveness and health risks were high. While both e-cigarette lifetime and never-users strongly supported cigarette smoking bans, endorsement for e-cigarette bans varied by lifetime use and intentions to use e-cigarettes.

CONCLUSIONS

Support for indoor e-cigarette bans is relatively low among individuals with a smoking history. Support for e-cigarette bans may change as evidence regarding their use emerges. These findings have implications for public health policy.

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.