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

Assessing the choice of smoke-free policies for multiunit housing and its associated determinants in Bangladesh: a cross-sectional study

OBJECTIVES

This study aimed to assess the desire for smoke-free housing, determine the choice of smoke-free policies for multiunit housing (MUH), and identify the factors associated with policy choice among MUH residents in Bangladesh.

DESIGN

We conducted a cross-sectional study from April to November 2019 using a semi-structured survey questionnaire.

SETTING

This study was conducted in seven divisional cities of Bangladesh: Dhaka, Chattogram, Rajshahi, Khulna, Sylhet, Barishal, and Rangpur.

PARTICIPANTS

A total of 616 adult individuals living in MUH for at least 2 years participated in the study.

PRIMARY OUTCOME MEASURE

Multinomial logistic regression was used to identify the determinants of the choice of smoke-free policies for MUH.

RESULTS

Overall, 94.8% of the respondents wanted smoke-free housing. Among those who wanted smoke-free housing, 44.9% preferred a smoke-free building policy, 28.3% preferred a smoke-free common area policy, 20.2% favoured a smoke-free unit policy, and 6.7% did not know what policy they should choose. Three factors were found to be significantly associated with the choice of a smoke-free building policy: staying at home for more than 12 hours (adjusted OR (aOR): 2.6; 95% CI 1.035 to 6.493), being a non-smoker (aOR: 3.2; 95% CI 1.317 to 7.582), and having at least one family member who smoked (aOR: 3.0; 95% CI 1.058 to 8.422). Results also showed that residents having at least one child under 15 in the family (aOR: 0.3; 95% CI 0.152 to 0.778) were less likely to choose a smoke-free common area policy and that women (aOR: 3.7; 95% CI 1.024 to 13.188) were more likely to choose a smoke-free unit policy.

CONCLUSIONS

MUH residents in urban Bangladesh highly demanded smoke-free housing. Most residents favoured a smoke-free building policy for MUH. Those who stayed at home for a longer time, were non-smokers, and had smoking family members were more likely to choose this policy.

Predictors of quitting smoking behavior: evidence from Pakistan

This study attempts to identify factors that significantly encourage the cessation of smoking in the context of Pakistan. The study distributes a modified questionnaire among 421 respondents (current as well as former smokers) in the capital city of Pakistan, Islamabad. The binary regression method was employed to data for analyzing predictors of making quit attempts and successful smoking cessation. The result indicates that respondents having strong intentions to quit, high socioeconomic status, low nicotine dependency, and past quit attempts, and those having no-smoking friends, are more likely to quit cigarette smoking successfully. On the other hand, factors like social pressure to quit smoking, religious information against smoking, intention to quit smoking, and public regulation on smoking are more likely to encourage smokers to make quit attempts. The study calls for community and school-wide smoking cessation campaigns involving officials, peers and parents, religious leaders, and other influential individuals to inform people about the dangers of smoking. In addition, religious leaders should be encouraged to issue rulings against smoking especially during "Friday Prayer." Furthermore, the government should pronounce more strict and comprehensive regulations on smoking by properly monitoring its implementation to encourage cessation of cigarette smoking.

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

INTRODUCTION

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

AIMS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Second-hand Smoke Exposure Among Home Care Workers (HCWs) in Scotland

OBJECTIVES

Second-hand tobacco smoke (SHS) is a serious cause of ill-health, and concern around SHS exposure at work has driven legislation in public places. In Scotland, most workers are now protected from SHS at work. However, home care workers (HCWs) may still be exposed, as they enter private homes where smoking is unregulated. In this study, we aimed to understand the extent, duration and intensity of that exposure among HCWs in Lanarkshire, Scotland.

METHODS

We surveyed HCWs in four organisations involved in providing care at home: a public healthcare agency (NHS Lanarkshire), two local government entities and a private healthcare company. We also conducted personal exposure monitoring (PEM) of exposure to airborne nicotine and SHS-related fine particulate matter (PM2.5) with 32 HCWs.

RESULTS

The vast majority of HCWs surveyed reported being exposed to SHS at work (395/537, 74%), and 50% of those who reported exposure in the home indicated daily exposure. We conducted PEM over 82 home visits, with 21% (17) demonstrating PM2.5 concentrations in excess of the WHO's 2010 air quality guideline limit for 24 h exposure. Duration of exposure to SHS tended to be short and as a result all nicotine samples were below the limit of quantification.

CONCLUSIONS

Most HCWs are exposed to minimal levels of SHS at work. However, a minority may be exposed to concentrations which affect health. Policies to mitigate this exposure should be considered, such as the use of respiratory protective equipment, improved ventilation during visits, and interventions to reduce smoking in homes.

Feasibility of low-cost particle sensor types in long-term indoor air pollution health studies after repeated calibration, 2019-2021

Previous studies have explored using calibrated low-cost particulate matter (PM) sensors, but important research gaps remain regarding long-term performance and reliability. Evaluate longitudinal performance of low-cost particle sensors by measuring sensor performance changes over 2 years of use. 51 low-cost particle sensors (Airbeam 1 N = 29; Airbeam 2 N = 22) were calibrated four times over a 2-year timeframe between 2019 and 2021. Cigarette smoke-specific calibration curves for Airbeam 1 and 2 PM sensors were created by directly comparing simultaneous 1-min readings of a Thermo Scientific Personal DataRAM PDR-1500 unit with a 2.5 µm inlet. Inter-sensor variability in calibration coefficient was high, particularly in Airbeam 1 sensors at study initiation. Calibration coefficients for both sensor types trended downwards over time to < 1 at final calibration timepoint [Airbeam 1 Mean (SD) = 0.87 (0.20); Airbeam 2 Mean (SD) = 0.96 (0.27)]. We lost more Airbeam 1 sensors (N = 27 out of 56, failure rate 48.2%) than Airbeam 2 (N = 2 out of 24, failure rate 8.3%) due to electronics, battery, or data output issues. Evidence suggests degradation over time might depend more on particle sensor type, rather than individual usage. Repeated calibrations of low-cost particle sensors may increase confidence in reported PM levels in longitudinal indoor air pollution studies.

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

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

Tobacco Industry Efforts to Respond to Smoke-Free Policies in Multi-Unit Housing: An Evaluation of Tobacco Industry Documents

The tobacco industry’s efforts to undermine clean indoor air policies in the hospitality industry, public spaces and workspaces is well documented, but less is known about their efforts to respond to the implementation of smoke-free policies in multi-unit housing (MUH). From 1988 to 2018, public and private multi-unit housing properties voluntarily implemented smoke-free polices in their buildings. We searched the UCSF’s Truth Tobacco Industry Documents Library to examine whether the tobacco industry responded to the implementation of these smoke-free policies in MUH using the same strategies they deployed to respond to smoke-free policies in other industries. We found that the tobacco industry used two primary strategies to respond to smoke-free policies in multi-unit housing: (1) distortion, which included funding studies that downplayed the link between SHS and asthma among low-income, inner-city MUH residents; and (2) deflection, which included engaging in corporate responsibility for youth living in low-income MUH. Despite these efforts, local jurisdictions continued to voluntarily implement smoke-free policies in MUH, pointing to a potential counter strategy to the tobacco industry influence.

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

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

Self-reported Secondhand Marijuana Smoke (SHMS) Exposure in Two New York City (NYC) Subsidized Housing Settings, 2018: NYC Housing Authority and Lower-Income Private Sector Buildings

The percentage of adults in the United States reporting current marijuana use has more than doubled, from 4 to 9% between 2002 and 2018, suggesting that exposure to secondhand marijuana smoke (SHMS) has probably increased. Few studies have characterized the extent to which residents experience SHMS, particularly those living in multi-unit housing. It remains unknown how recently-implemented smoke-free housing policies (SFH) targeting cigarette smoke in public housing authorities (PHAs) will affect SHMS exposure. We sought to characterize prevalence of self-reported SHMS exposure among residents living in two different subsidized housing settings prior to SFH policy implementation in PHAs: New York City Housing Authority (NYCHA) buildings and private sector buildings where most residents receive Section 8 subsidy vouchers (herein 'Section 8' buildings). Residents were recruited from 21 purposefully-selected buildings: 10 NYCHA and 11 Section 8 buildings (> 15 floors). Survey responses were collected during April-July 2018 for NYCHA residents (n = 559) and August-November 2018 for Section 8 residents (n = 471). Of 4628 eligible residents, 1030 participated (response rates, 35% NYCHA, 32% Section 8). Overall, two-thirds of residents reported smelling marijuana smoke (67%) in their home over the past year, higher than reports of smelling cigarette smoke (60%). Smoking status and smelling SHS were both strong predictors of smelling SHMS (p < 0.05). Nearly two thirds of residents perceived smoking marijuana and smelling SHMS as harmful to health. Our findings suggest that, immediately prior to SFH rule implementation in PHAs, SHMS was pervasive in low-income multi-unit housing, suggesting SFH policies should expand to cover marijuana use.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

EXPOSURES

Federal SFH policy implementation, beginning July 30, 2018.

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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